bluuebunny/crossref_metadata_2025 huggingface dataset:
Pelvic Fracture Risk Assessment on Admission
Authors: Sharma Om P. , Oswanski Michael F. , Rabbi Jamal , Georgiadis Gregory M. , Lauer Sherry K. , Stombaugh Heather A.
Published: June 2020

Patients with pelvic fractures (PF) have high incidences of associated injuries and mortality. To identify patients with PF at the highest risk for mortality on admission to a Level I trauma center, investigators analyzed 566 PF in 12,128 patients (1996 to 2005). PF were categorized on arrival as high risk (HR) or low risk (LR) by initial blood pressure, examination, radiographs, and CT. HR PF included open fractures, open-book injuries, PF 4 or greater abbreviated injury score, and hypotension (89 mmHg or less systolic blood pressure); all other cases were categorized as LR PF. Patients with PF had 6 per cent (35 of 566) mortality compared with 3 per cent (300 of 11,529) without PF. Mortality was 24 per cent (25 of 103) in HR PF, including 11 per cent (one of nine) of open fractures, 25 per cent (12 of 49) of open-book injuries, 23 per cent (14 of 62) of 4 or greater abbreviated injury score, and 33 per cent (20 of 60) of hypotensive patients compared with 3 per cent (13 of 454) of LR PF. Compared with LR PF, patients with HR PF were younger (43.5 vs 53.8 years) with higher injury severity scores (28.7 vs 11.9) and longer hospital stays (10.6 vs 7.4 days). PF mortality remains high despite treatment in a Level I trauma center. Trauma mechanism, initial blood pressure, pelvic radiography, and CT can be used to predict a patient's mortality risk.
Measuring Intra-Abdominal Pressure outside the ICU: Validation of a Simple Bedside Method
Authors: Cheatham Michael L. , Fowler Jessica
Published: June 2020

Intra-abdominal pressure measurement is essential to the diagnosis of patients with intra-abdominal hypertension or abdominal compartment syndrome. The most common method for measuring intra-abdominal pressure (IAP) is the intravesicular or “bladder” technique, which requires electronic monitoring technology not available on the typical surgical ward. Herein we describe and validate a simple, rapid screening method for bedside IAP measurement using the patient's indwelling urinary catheter and a readily available intravenous tubing extension. Validation of this technique across the clinically important IAP diagnostic spectrum demonstrated acceptable bias (1.6 mm Hg; 95% confidence interval 1.4–1.8) with limits of agreement of 0.36 to 2.8. This demonstrates good agreement between the two IAP methods and validates the bedside technique as a simple, cost-effective, and reproducible method for screening IAP measurements outside of the critical care setting.
Intra-Abdominal Lesions Could be Missed by Inadequate Laparoscopy
Authors: Hsu Tzu-Chi
Published: June 2020

Laparoscopic resection has become one of the choices for colectomy for various colon and rectal diseases in recent years. Despite some uncertainties of laparoscopic procedures, especially during cancer surgery, its popularity has forced surgeons to pursue the approach. One of the concerns is inadequate examination of the intra-abdominal organs with a laparoscope. This study is a retrospective analysis of a single surgeon's experience of the frequencies of unexpected findings during laparotomies. From July 1990 to November 2005, 2775 patients with various colorectal diseases receiving laparotomies by a single surgeon were analyzed. Among them, 2282 patients were operated for primary colorectal cancer. Excluded were patients who did not receive a formal laparotomy, who had a recent laparotomy, who had peritoneal and omental metastasis, and whose pathology did not attract attention for management. Exploration of the entire peritoneal cavity was performed for all cases in the series. There were 1423 males and 1352 females. Ages ranged from 12 to 94 years, averaging 62.6-years-old. Forty-six patients (1.7%) were found to have unexpected intra-abdominal lesions during laparotomies. Eleven patients were found to have synchronous colorectal cancers; five patients were found to have unexpected liver metastases; three patients each were found to have gastric cancers, stromal tumors of the small bowel, and ectopic pancreas; two patients each were found to have gastric leiomyosarcomas, pancreatic cancers, mucoceles of the appendix, ulcers of the small intestine, bleeding Meckel's diverticula, pancreatitis, and perforations of the ileum; one patient each was found to have gall bladder cancer, malignant carcinoid tumor, pheochromocytoma, diverticulitis of the jejunum, diverticulitis of the colon, duplication of the colon, and aortic aneurysm larger than 6 cm. Forty-one of the lesions were likely to be missed by laparoscope. This experience suggests that incomplete laparotomies might miss various pathologies. Laparoscopy is not a complete form of laparotomy because of loss of tactile sensation. Laparoscopy might result in an inadequate or inappropriate management due to misdiagnosis.
Bleeding Complications with Drotrecogin Alfa Activated (Xigris®): A Retrospective Review of 31 Operative and 68 Non-Operative Patients with Severe Sepsis
Authors: Taylor Benedict J.W. , Lee Sarah J. , Waxman Kenneth
Published: June 2020

We reviewed 100 consecutive patients who received Drotrecogin alfa (activated) (DAA) (Xigris®, Eli Lilly, Indianapolis, IN) for the treatment of severe sepsis and compared the incidence of bleeding complications in surgical (n = 30) and nonsurgical cohorts (n = 70). Thirty patients who received DAA therapy for severe sepsis underwent one or more contemporaneous surgical procedures. These were compared with 70 DAA patients who did not undergo surgery. During the course of DAA administration, transfusion of greater than three units of blood, an intracranial hemorrhage, or other bleeding serious adverse event were qualified as bleeding complications. Overall, we identified seven patients who fulfilled the designated bleeding complication criteria, four in the surgical cohort, and three in the nonsurgical cohort. There was no significant difference in the rate of bleeding complications between surgical and nonsurgical cohorts (P = 0.1063). Moreover, there were no mortalities ascribed to bleeding and there were no intracranial hemorrhage events. All bleeding complications were due to a drop in hemoglobin or platelets only, and were treated with transfusion. Our experience demonstrates that there is an equivalent risk of bleeding for surgical patients treated with DAA compared with nonsurgical patients. Additionally, all bleeding complications were amenable to simple transfusion.
Skin-Sparing Mastectomy: A Survey Based Approach to Defining Standard of Care
Authors: Shen Jeannie , Ellenhorn Joshua , Qian Dajun , Kulber David , Aronowitz Joel
Published: June 2020

Skin-sparing mastectomy (SSM) followed by immediate reconstruction has been advocated as an effective treatment option for patients with early-stage breast carcinoma. It markedly improves the quality of breast reconstruction through preservation of the natural skin envelope and a smaller incision. The purpose of this study was to investigate general surgeons’ attitudes towards SSM. A postal questionnaire survey of California general surgeons was conducted regarding SSM. Of 370 respondents who stated they performed breast cancer surgery, 331 perform mastectomy for cancer with planned immediate reconstruction. Ninety per cent of respondents did not feel that SSM resulted in higher rates of local recurrence. In addition, 70 per cent felt that the cosmetic results of immediate breast reconstruction after SSM were better than those after a standard mastectomy. Despite this, only 61 per cent perform SSM in most cases when immediate breast reconstruction is planned. The majority of general surgeons perform SSM and therefore it should be considered standard of care. Despite a growing body of literature demonstrating high rates of patient satisfaction and long-term oncologic safety with SSM, there remains significant variation in practice patterns among general surgeons. Additional effort in general surgery education regarding the feasibility and safety of SSM is needed.
Long-Term Outcome of Endorectal Advancement Flap for Complex Anorectal Fistulae
Authors: Abbas Maher A. , Lemus-Rangel Rafael , Hamadani Ali
Published: June 2020

The purpose of this study was to determine the long-term outcome of endorectal advancement flap (ERF) for complex anorectal fistulae. A total of 38 ERF were performed in 36 patients (2003–2007). Mean age was 45 years. The most common fistula type was transsphincteric. Eighty-one per cent of patients had prior surgical interventions. Primary closure rate was 83 per cent. Of the six initial failures, four were noted in patients operated for recurrent rectovaginal fistula. Postoperative complications occurred in seven patients (19%). During a mean follow-up of 27 months, recurrent disease was noted in five patients (14%). All recurrences were noted in patients with left sided fistulae. At last follow-up, all patients had healed their fistula except for two. We conclude that ERF closed most complex anorectal fistulae with an acceptable complication rate and low recurrence rate. Recurrent rectovaginal fistula was associated with a lower closure rate.
Outcomes of Esophagectomy at Academic Centers: An Association between Volume and Outcome
Authors: Reavis Kevin M. , Smith Brian R. , Hinojosa Marcelo W. , Nguyen Ninh T.
Published: June 2020

Studies have shown that esophagectomies performed at high-volume centers have lower in-hospital mortality. However, the volume-outcome relationship for esophagectomy performed at academic centers is unknown. Using the University HealthSystem Consortium national database, we examined the influence of the hospital's volume of esophagectomy on outcome at academic centers between January 2003 and October 2007. Outcomes including length of stay, 30-day re-admission, morbidity, and observed and expected mortality were compared between high (>12), medium (6–12), and low-volume centers’ (≤5) annual cases. There were 30 high (n = 3984), 23 medium (n = 822), and 54 low-volume (n = 430) hospitals. Compared with low-volume counterparts, high-volume hospitals had shorter lengths of stay (14.1 vs 17.2 days, P < 0.01), fewer overall complications (51.1% vs 56.5%, P = 0.03), fewer cardiac complications (1.1% vs 2.5%, P = 0.01), fewer pulmonary complications (18.5% vs 29.8%, P < 0.01), fewer hemorrhagic complications (3.2% vs 6.7%, P < 0.01), fewer patients requiring skilled nursing facility care (9.5% vs 19.7% P < 0.01), and lower in-hospital mortality (2.5% vs 5.6%, P < 0.01). The observed-to-expected mortality ratio was 0.6 for high-volume and 1.0 for low-volume centers. Within the context of academic centers, there is a threshold of >12 esophagectomies annually whereby there is a lower mortality and improved outcome.
Blood Transfusions in Trauma: Six-Year Analysis of the Transfusion Practices at a Level I Trauma Center
Authors: Teixeira Pedro G.R. , Oncel Didem , Demetriades Demetrios , Inaba Kenji , Shulman Ira , Green Donald , Plurad David , Rhee Peter
Published: June 2020

The objective of this study was to analyze the transfusion practices in trauma patients in one institution. A retrospective analysis of the Trauma Registry linked with the Blood Bank Database of a Level 1 trauma center was conducted. Over 6 years, 17 per cent of the 25,599 trauma patients received blood transfusions. The overall mortality in transfused patients was 20 per cent and remained the same during the study period. There was no change in the proportion of patients receiving transfusions throughout the years, however there was a significant 23.5 per cent reduction in the mean number of packed red blood cells (PRBC) units transfused (P < 0.001 for trend). This reduction in PRBC used remained true and even more evident in the group of more severely injured patients (Injury Severity Score ≥ 16), with a 27.9 per cent decrease in mean units of PRBC (P < 0.001 for trend). The highest reduction in PRBC transfusion was seen in blunt trauma patients (34.6%, P < 0.001). During the study period there was a concurrent increase in mean units of fresh frozen plasma used (60.7%, P < 0.001) and no change in the use of platelets and cryoprecipitate. In conclusion, transfusions of PRBC were significantly reduced over time in trauma patients without any evident negative impact on mortality.
Management of High-Grade Splenic Injury in Children
Authors: Jim Jeffrey , Leonardi Michael J. , Cryer H. Gill , Hiatt Jonathan R. , Shew Stephen , Cohen Marilyn , Tillou Areti
Published: June 2020

Using the National Trauma Databank, we identified 413 children (age ≤ 14 years) who sustained high-grade blunt splenic injury (Abbreviated Injury Scale scores ≥4) from 2001 to 2005. Overall mortality was 13.5 per cent. Early operation within 6 hours of injury (EOM) was performed in 128 patients (31%). Patients not undergoing EOM (n = 285) were assumed to have been treated with initial nonoperative management (NOM). NOM was successful in 84 per cent of patients. Operative intervention was necessary in 42 per cent of cases with 74 per cent of these undergoing early operation (EOM). Total splenectomy was the most common procedure (83%). EOM and failure of NOM were both associated with lower systolic blood pressure and lower Glasgow Coma Scale score at admission, higher Injury Severity Score, longer hospital stay, and higher mortality. Need for surgery was independent of patient age and gender. Failure of NOM was associated with increased mortality compared with successful NOM, but had similar mortality and length of hospital or intensive care unit stay compared with EOM. We conclude that operative treatment is necessary in nearly half of pediatric patients with high-grade splenic injury. With careful selection, nonoperative management is usually successful but must include close monitoring, because 16 per cent required delayed operation.
Surgical Resident and Attending Physician Attitudes toward Glucose Control in the Surgical Patient
Authors: Costantini Todd W. , Acosta Jose A. , Hoyt David B. , Ramamoorthy Sonia
Published: June 2020

Hyperglycemia is a common occurrence in postoperative surgical patients and has been related to adverse outcomes, including increased infections, delayed wound healing, and increased postoperative mortality. Therefore, the management of hyperglycemia has become an increasingly important part of surgical practice. A 16-point questionnaire was distributed to general surgery housestaff and attending physicians at three teaching hospitals in southern California. The survey was scaled 1 to 5 (1, strongly disagree; 5, strongly agree). Answers of 1 and 2 were considered a negative response, whereas 4 and 5 were considered affirmative responses. There were 105 survey respondents (60 surgical residents, 45 surgical attendings). Only half of respondents were confident in their ability to adequately control blood sugar in their hospitalized patients. Approximately 60 per cent of attendings rely on residents to manage glucose control. Less than half of the attendings (49%) and less than one-third of residents (27%) stated they were current with the latest guidelines for glucose control. Only one-third of the attendings would consult an internist or endocrinologist to assist in glycemic management. This study reveals an important knowledge deficit among surgical resident and attending physicians. Focused education on glycemic control in the perioperative patient should be a mandatory component of surgical training.
How to Measure the Quality of Surgery-Related Web Sites
Authors: Yermilov Irina , Chow Warren , Devgan Lara , Makary Martin , Ko Clifford Y.
Published: June 2020

Appropriateness and adequacy of health information on the Internet varies. Given there is no validated instrument for web site evaluation focusing on elective general surgical procedures, our goal was to create a composite score as a web site quality rating system. The components of a composite score were developed through a literature review and included Agency for Healthcare Research and Quality guidelines of “Having Surgery? What You Need to Know” and previously published health-related web site scales. All criteria are given equal weight (0/1 scale). The composite score is reported as a percentage of a total possible 16 points. To pilot the rating scale, a web search for roux-en-y gastric bypass (RYGB) was used. Validation compared the composite score with an evaluation by surgeons. Mean composite score for 18 RYGB web sites was 48 per cent (range, 19% to 75%). Composite score validation used a cutoff value of 50 per cent. There was 100 per cent agreement (kappa = 1.0) between composite and surgeon scores. This is the first validated comprehensive composite score to evaluate the web site quality for patients undergoing elective surgery. This score shows promise in increasing efficiency of surgical practices by providing a way in which we can evaluate web sites and encourage our patients to become well informed by reading only high-quality web sites.
The Surgical Care Improvement Project (SCIP) Initiative to Reduce Infection in Elective Colorectal Surgery: Which Performance Measures Affect Outcome?
Authors: Nguyen Nhien , Yegiyants Sara , Kaloostian Carolyn , Abbas Maher A. , Difronzo L. Andrew
Published: June 2020

One component of the Surgical Care Improvement Project (SCIP) is the prevention of surgical site infections (SSIs) by: 1) timing the administration of prophylactic antibiotics (PAs) within 1 hour of incision; 2) using approved PA regimens; and 3) discontinuing PA within 24 hours. We sought to evaluate institutional compliance with SCIP recommendations in patients undergoing elective colorectal surgery and determine whether they affected the incidence of SSI. One hundred four elective colorectal cases were reviewed. In 58 patients (56%), PAs were administered within 1 hour of incision. In 71 cases (68%), the PA choice was considered compliant. There were a total of 12 SSIs (11.5%) overall. The incidence of SSI was significantly higher in cases in which PAs were not administered within 1 hour of incision (10 of 46 or 22% vs two of 58 or 3.5%, P = 0.005). There was no significant difference in the incidence of SSI in patients who received compliant versus noncompliant PA (12.7% vs 9.1%, P = 0.75). Timely PA administration significantly reduces the incidence of SSI in patients undergoing elective colorectal surgery. Efforts should focus on ensuring that PAs are given in a timely manner to reduce SSI in colorectal surgery.
Management and Outcomes of Ovarian Masses in Children and Adolescents
Authors: Islam Saleem , Yamout Sani Z. , Gosche John R.
Published: June 2020

Ovarian masses in the pediatric age group are rare, and malignancies are even less common. We reviewed our large single-center experience to determine the rate of malignancy and discuss management. We retrospectively reviewed the cases of ovarian masses in children in our institution over a 10-year period. Demographic and tumor-specific data were reviewed and analyzed, and a Student's unpaired t test was used where appropriate. A total of 49 children and adolescents with ovarian masses were found. The mean age at presentation was 13.3 years. Eight masses were malignant (16%) with malignant teratoma, dysgerminoma, and germ cell tumors found. These patients responded to chemotherapy, but there were three recurrences noted that responded to further therapy. Seventy-four per cent of the benign tumors were teratomas. The most common presentation was abdominal pain in 27 patients (55%) followed by an abdominal mass. Ultrasound and CT scans were the most common imaging studies with a mean mass size of 14.7 cm. A majority of the patients underwent a laparotomy with 12 per cent having a minimally invasive procedure. Only 37 per cent of the operations were performed by the pediatric surgeons. There were no deaths in this series after a follow up of over 6 years. Most ovarian masses in childhood are benign. Malignant lesions have favorable outcomes with chemotherapy, even with recurrent disease. Consideration for laparoscopic procedures should be given for the benign lesions.
Sterile Intra-Abdominal Fluid Collection Associated with Seprafilm Use
Authors: Tyler Joshuaa , Mcdermott Dustin , Levoyer Thomas
Published: June 2020

Postoperative abdominal adhesions are a significant cause of morbidity and expenditure of healthcare resources. As a result, numerous substances have been studied in an effort to reduce the incidence of adhesive disease. Seprafilm, a hyaluronate-based bioresorbable membrane, has been the subject of considerable research and has been found to be both safe and effective in reducing postoperative adhesions. We report three cases of the development of sterile abdominal fluid collection after the use of Seprafilm in colorectal surgery.
The Role of Laparoscopy in Trauma: A Ten-Year Review of Diagnosis and Therapeutics
Authors: Mallat Ali F. , Mancini Matthew L. , Daley Brian J. , Enderson Blaine L.
Published: June 2020

Minimally invasive surgery has found many applications in general surgery. The role of laparoscopy in trauma has been debated as a diagnostic, as well as therapeutic, tool in hemodynamically stable patients. This study evaluated laparoscopy in the trauma population. A retrospective review of all laparoscopies performed in hemodynamically stable trauma patients from 1996 until 2006 was conducted. Mechanisms of injury, perioperative data, and demographic variables were analyzed using descriptive statistics and Student's t test. Exploratory diagnostic laparoscopy was performed on 102 patients. Laparoscopy was negative for 65 per cent of patients; 12 per cent of these were converted to laparotomy due to adhesions, hemoperitoneum, or surgeon preference. None of the conversions revealed intra-abdominal injury at laparotomy. An injury was diagnosed at laparoscopy in the remaining 35 per cent, with 55 per cent conversion rate to repair the injury. Therapeutic laparoscopy included serosal repair, hemorrhage control, diaphragmatic repair, and other standard laparoscopic treatments. No patient required re-exploration, there were no missed injuries or other complications, and no patient died in this study. Laparoscopy has an important diagnostic and therapeutic role in selected hemodynamically stable trauma patients. Using a minimally invasive approach can reduce the potential morbidity of negative laparotomy.
The Cuff Leak Test is Not Predictive of Successful Extubation
Authors: Shin Susanna H. , Heath Kirk , Reed Scott , Collins Jay , Weireter L.J. , Britt L.D.
Published: June 2020

In intubated patients the presence of a cuff leak (CL) is used as a predictor of successful extubation. CL is proposed to indicate laryngeal edema and predict which patients may develop complications such as postextubation stridor and eventual reintubation. Our objective was to evaluate the reliability of CL in our population of critically ill trauma patients. A retrospective chart review was performed of patients admitted to the trauma service who required mechanical ventilation. All patients undergo the CL test by a single respiratory therapist team before attempted extubation. Data collected included body mass index (BMI), endotracheal tube (ETT) size, length of time of mechanical ventilation, tidal volumes (Vt), and the size of the patient's trachea based on CT scan. The test is performed by the respiratory therapists and involves measuring expired Vt before and after the ETT cuff has been deflated and listening for an audible leak. A positive test result is defined as a CL greater than 10 per cent of Vt or, when volumes are not available, as audible air expired. From October 2005 to May 2006, 150 mechanically ventilated patients were identified and 49 charts were available for review. Forty-one patients had a cuff leak (+CL), whereas eight did not (-CL). The two cohorts were similar in age (+CL = 36.5 years, –CL = 38.1 years, P = 0.82), male gender (+CL = 70%, -CL = 50%, P = 0.25) ETT size (+CL = 7.4, –CL = 7.4, P = 0.57), and BMI (+CL = 28 kg/m2, -CL = 27 kg/m2, P = 0.71). The average tracheal diameter (+CL = 17.4 mm, -CL = 17.5 mm, P = 0.90) as well as the ratio of ETT and tracheal diameter was similar for the two cohorts (+CL = 0.65, –CL = 0.64, P = 0.73). Four patients (10%) in the +CL cohort failed extubation, whereas none of the –CL cohort failed (0%) (P = 0.40). The CL test does not reliably identify those patients who will require reintubation in our trauma population. In addition, the ratio of ETT and tracheal diameter is not predictive of successful extubation.
Is Endoscopic Resection of Gastric Gastrointestinal Stromal Tumors Safe?
Authors: Waterman Alyson L. , Grobmyer Stephen R. , Cance William G. , Hochwald Steven N.
Published: June 2020

Gastric gastrointestinal stromal tumors (GIST) commonly present as an incidental finding on upper gastrointestinal endoscopy. Advances in endoscopic technology have allowed some to perform attempted excision of these lesions endoscopically. The oncologic implications of such an approach remain unclear. A-74-year-old man initially presented with an incidental finding of a 1.6 x 1.8-cm c-kit-positive gastrointestinal stromal tumor with low mitotic activity in the gastric fundus. The patient underwent an attempted endoscopic resection of this mass resulting in incomplete excision and gastric perforation. There was immediate conversion to a celiotomy and the patient underwent partial gastrectomy; there was no evidence of metastatic GIST. Three years later, the patient was noted to have an asymptomatic large pelvic mass (4 x 7 cm) on CT scan and was referred for evaluation. Subsequent surgical exploration revealed a single mass adherent to the pelvic sidewall that was resected. Subsequent pathology demonstrated a c-kit-positive GIST consistent with metastatic disease. Eighteen months later, the patient remains free of disease. Complications from endoscopic resection of gastric GIST may be associated with peritoneal dissemination of disease. This should be considered when formulating a strategy for management of gastric GIST. Complete transperitoneal excision (either open or laparoscopic) with clear margins and without tumor rupture remains the gold standard for management of gastric GIST.
Prevalence and Management of Gastrointestinal Stromal Tumors
Authors: Machado-Aranda David , Malamet Matthew , Chang Yeon-Jeen , Jacobs Michael J. , Ferguson Lorenzo , Silapaswan Sumet , Goriel Yousif , Kolachalam R. , Mittal Vijay K.
Published: June 2020

The prevalence and characteristics of patients with confirmed gastrointestinal stromal tumor (GIST) in a community hospital over a 6-year period are described. Our objective was to communicate our experience managing this rare tumor of the gastrointestinal tract. A retrospective chart review was performed. Patients were selected based on International Classification of Diseases, 9th Revision codes in correlation with their respective confirmational pathology. Patients with a diagnosis of GIST, cells of Cajal tumor, and/or different varieties of gastrointestinal sarcoma were included in this study. These tumors had to have a positive C-kit on immunohistochemistry. Demographic and clinical data were collected from medical records as well as pathology reports. Follow up from attendings’ office records and telephone interviews complemented our data. A total of 61 patients was identified in our institution (averaging 10 patients per year). Females represented 63 per cent of our series. The average ages were 70.2 ± 19.1 years for females and 59.4 ± 13.5 years for males ( P < 0.01). The most common clinical presentation was an intra-abdominal nonobstructing mass followed by an endoscopically detected mass or incidental tumors found during unrelated surgery. Surgical emergencies such as acute abdomen and gastrointestinal bleed were rare. Over half of these tumors were located in the stomach. Other sites were the small intestine, colon, esophagus, and rectal–vaginal septum. Opened surgical resection was performed in two-thirds of treated cases, whereas laparoscopic resection was done in the remainder. Only 18 per cent of these tumors were considered benign, whereas 35 per cent were considered to have some malignant potential and 47 per cent were of undetermined potential. In surgically resected tumors, we found a 42 per cent recurrence rate with a median average time of recurrence of 22 months. Pathologic grading and type of surgery were not predictors of rate and timing of recurrence. However, the disease tended to be more aggressive in white males and age older than 70 years. Imatinib was used mainly in attempts to downstage, control recurrent disease, and make surgery possible. With the improvement of immunohistochemical techniques, the diagnosis of GIST is increasing. Preoperative diagnosis is highly uncertain and dependent on clinical suspicion. Surgical resection is still the main form of curative therapy. Our experience is similar to large-volume centers. GIST, once recognized, can be treated in community hospitals without compromise of their care.
Arterial Complications of Thoracic Outlet Syndrome
Authors: Davidović Lazar B. , Končar Igor B. , Pejkić Siniša D. , Kuzmanović Ilija B.
Published: June 2020

Arterial complications of thoracic outlet compression have serious potential implications; however, these complications rarely appear. Between 1990 and 2006, prospectively collected data on 27 patients with arterial complications of thoracic outlet syndrome were analyzed. The causes of arterial compression were cervical rib (20 [74.1%]), abnormalities of the first thoracic rib (three [11.1%]), soft tissue anomalies (two [7.4%]), and hypertrophic callus after clavicle fracture (two [7.4%]). In all cases, a combined supraclavicular and infraclavicular approach was used. Decompression was achieved by cervical rib excision in 13 (48.1%) patients, combined cervical and first rib excision in seven (26%), and first rib excision in six (22.2%). Associated vascular procedures included resection and replacement of the subclavian artery (26 [97.3%]), one subclavian–axillary and one axillary–brachial bypass as well as 17 (63%) brachial embolectomies. The mean follow-up period was 7 years 4 months (range, 1-16 years). Two pleural entries, two transient brachial plexus injuries, and one subclavian artery rethrombosis were found. Complete resolution of symptoms with a return to full activity was noted in all cases. In surgical treatment, a combined anterior supraclavicular and infraclavicular approach is recommended as well as transbrachial embolectomy in all cases with symptoms of distal embolization.
Alcohol's Role on the Reliability of Clinical Examination to Rule Out Pelvic Fractures
Authors: Duane Therèse M. , Dechert Tracey , Wolfe Luke G. , Brown Holly , Aboutanos Michel B. , Malhotra Ajai K. , Ivatury Rao R.
Published: June 2020

The objective of this study was to determine if clinical examination accurately ruled out pelvic fractures in intoxicated patients sustaining blunt trauma A prospective comparison of intoxicated (blood alcohol level [BAL] greater than 0.08 g/dL) to nonintoxicated (BAL less than 0.08 g/dL) patients sustaining blunt trauma was performed between February 2004 and March 2007. Clinical factors were compared and subset analysis performed in which patients with factors known to compromise the clinical examination were excluded. Two hundred ninety-six intoxicated patients were compared with 1071 nonintoxicated patients. Intoxicated patients were younger and more often male. Intoxicated patients had a higher heart rate (97.1 beats/min ± 17.9 vs 91.4 beats/min ± 18.7, P < 0.0001) and lower systolic blood pressure (136.2 mmHg ± 21.2 vs 141.9 mmHg ± 26.6, P = 0.0005) than nonintoxicated patients. Intoxicated patients had a lower incidence of pelvic fracture (6.1 vs 10.6%). In subset analysis, the majority of the intoxicated patients did not have exclusion factors on examination and could be evaluated (66.6%). There were eight pelvic fractures diagnosed in this group and no missed injuries on clinical examination (sensitivity 100%). Clinical examination was not compromised by intoxication. Routine pelvic x-rays are not needed in the alert, intoxicated patient sustaining blunt trauma.
Elective Inguinal Hernia Repair: A Unified Informed Consent, or who Wants to Know What?
Authors: Losanoff Julian E. , Litwinczuk Kathleen M. , Ranella Michael J. , Basson Marc D.
Published: June 2020

Informed consent is increasingly being standardized. We sought to evaluate variability in the amount and quality of information desired by patients in choosing whether to undergo elective surgical hernia repair, a prototypical low- to moderate-risk common procedure. Consecutive stable outpatients were asked to assume that they were considering hernia repair and interviewed with a standard questionnaire that asked them to rate their interest in learning about the natural history, pathology, and management of inguinal hernia as well as herniorrhaphy complications and postoperative recovery. Ninety-eight consecutive patients exhibited substantial interpersonal variability in their level of interest in receiving information. Although interest in some types of information tended to correlate with interest in other types of information, patients’ degree of interest in receiving information about anesthesia during the procedure was independent of other variables. Education and previous exposure to individuals with hernias also affected interest in receiving potentially important information before deciding whether to consent to hernia surgery. Patients may vary with regard to the information they want to receive when deciding whether to consent to an invasive procedure. It may be preferable to individualize the consent process to patients’ preferences rather than adhering to standardized content.
Treatment of Hyperinsulinemic Hypoglycemia Due to Diffuse Nesidioblastosis in Adults: A Case Report
Authors: Toyomasu Yoshitaka , Fukuchi Minoru , Yoshida Takatomo , Tajima Kohei , Osawa Hidenobu , Motegi Masahiko , Iijima Toshihide , Nagashima Kikuo , ishizaki Masatoshi , Mochiki Erito , Kuwano Hiroyuki
Published: June 2020

An 82-year-old man was admitted to our hospital with a complaint of hypoglycemic syncope in the early morning. Insulinoma was suspected, but an abdominal CT showed no mass. Abdominal angiography showed a slight stain fed from the splenic artery. Arterial stimulation and venous sampling (ASVS) showed an abnormal insulin response only from the splenic artery. Under a provisional diagnosis of insulinoma, surgical treatment was undertaken. Although no pancreatic masses were palpable, we performed a distal pancreatectomy. Subsequently, a pathological examination revealed diffuse nesidioblastosis. Reported cases of diffuse nesidioblastosis have had common clinical features: postprandial hyperinsulinemic hypoglycemia, no abnormal findings in radiological examinations, and the presence of the ductulo-insular complex on histological examination. Surgical resection is recommended, but the extent of surgery is controversial. Our case had some clinical features of insulinoma but was diagnosed as diffuse nesidioblastosis according to histopathologic criteria. Because ASVS showed that the pancreatic body and tail had a lesion producing insulin abnormally, we performed a distal pancreatectomy to cure the hypoglycemia. Clinically, it is very difficult to distinguish diffuse nesidioblastosis from insulinoma. When we treat hyperinsulinemic hypoglycemia, ASVS can be an essential examination to decide the extent of pancreatectomy.
Carcinosarcoma of the Colon: A Rare Cause of Colovesical Fistula
Authors: Patel Dhaval H. , Dang Shyam , Bentley Frederick R. , Julka Rahul N. , Olden Kevin W. , Aduli Farshad
Published: June 2020

Carcinosarcomas are relatively rare tumors composed of both carcinomatous and sarcomatous components. The most common sites involved by this tumor are the head and neck, respiratory tract, uterus, ovaries, and fallopian tubes. Within the gastrointestinal tract this tumor most often occurs in the esophagus, followed by the stomach. Carcinosarcomas are very aggressive tumors associated with a poor prognosis. The first case of carcinosarcoma of the colon was reported in 1986. The case reported here is the only one involving an associated colovesical fistula.
Industry Support of Graduate Medical Education in Surgery
Authors: Nakayama Don K. , Bozeman Andrew P.
Published: June 2020

The role of pharmaceutical and medical device companies (“industry”) in graduate medical education (GME) is under debate. We surveyed program directors in general surgery and surgical specialties to determine industry activities in surgical GME. We used an internet-based questionnaire regarding industry marketing and educational activities in surgical programs, and their effects on surgical education. We received 65 responses to 377 requests (17%). Nearly two-thirds reported industry-sponsored meals. Industry-supported travel was infrequent (“never” and “seldom” in 56% of device workshops, 69% of lectures, and 74% of conferences). More than one-half reported support for academic events: paid lecturers and exhibition fees (both 58%), and unrestricted grants (62%). More than one-half (54%) reported industry-sponsored research. One-fourth believed their programs to be dependent on industry for their educational missions. Most disagreed that industry support posed a problem, either in general (55%) or for their program (71%). One-fourth of respondents (25%) advocated profession-wide restrictions of industry involvement with GME. Equal numbers agreed (39%) and disagreed (35%) with the view that pharmaceutical and medical device industries have motivations that are in conflict with those of doctors and their patients. Industry activities are widespread in surgical residencies, with approval of many program directors.
Retrievable Inferior Vena Cava Filters Are Rarely Removed
Authors: Gaspard Scott F. , Gaspard Donald J.
Published: June 2020

There has been an increasing nationwide trend of inferior vena cava (IVC) filter placement over the past 3 years. Most of these have been the newer, removable variety. Although these are marketed as retrievable, few are removed. The purpose of this study was to examine the practice pattern of IVC filter placement at Huntington Hospital. This study is a retrospective chart review of all IVC filter placements and removals between January 1, 2004, and December 31, 2006. The primary data points include indication for placement, major complications (migration, caval thrombosis, pulmonary embolus [PE]), attempted removal, and successful removal. Three hundred ten patients received IVC filters at our institution during this period. Eighty-four were placed in 2004, 95 in 2005, and 131 in 2006. Of those, only 12 (3.9%) were documented permanent filters, whereas the remainder (298) were removable. Of the retrievable filters placed, only 11 (3.7%) underwent successful removal. There were four (1.3%) instances in which the filter could not be removed as a result of thrombus present within the filter and two (0.67%) in which removal was aborted as a result of technical difficulty. Our use of IVC filters has increased steadily over the last 3 years. Despite the rise in use of “removable” filter devices, few are ever retrieved. Although IVC filter insertion appears an effective method of PE prevention, it comes at a cost, both physiological and monetary. It would be wise to devise more stringent criteria to identify those patients in the various populations who truly require filter placement and to be cautious in altering our indications for placement.
Methicillin-Resistant Staphylococcus aureus in a Trauma Population: Does Colonization Predict Infection?
Authors: Croft Chasen A. , Mejia Vicente A. , Barker Donald E. , Maxwell Robert A. , Dart Benjamin W. , Smith Philip W. , Burns R. Phillip
Published: June 2020

Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly responsible for infections in hospitalized patients. Patients colonized with MRSA appear to be at higher risk for subsequent MRSA infections than those who are not colonized. In this study, we determined MRSA colonization status of trauma patients at hospital admission and compared the incidence of subsequent MRSA infections between MRSA colonized and noncolonized patients. Collected data were entered into databases at a single, Level I trauma center over a 13-month period. Three hundred fifty-five adult trauma patients were screened for MRSA on admission to the trauma intensive care unit. The patients were categorized into two groups, those colonized with MRSA at admission and those who were not. Thirty-six of 355 patients (10.1%) were colonized. Of the 319 patients not colonized, 21 (6.6%) developed MRSA infections. Twelve of 36 (33.3%) colonized patients developed MRSA infections ( P < 0.001). No differences in types of MRSA infections were found between the two groups. Colonized patients who developed MRSA infections had higher death rates, 22.2 versus 5.0 per cent ( P < 0.001). Patients colonized with MRSA on admission may be at higher risk for developing MRSA infections during hospitalization. MRSA screening protocols should be used to identify these at-risk patients.
Perioperative Management of Cholelithiasis in Patients Presenting for Laparoscopic Roux-en-Y Gastric Bypass: Have we Reached a Consensus?
Authors: Patel Jitesh A. , Patel Nilesh A. , Piper Greta L. , Smith Deane E. , Malhotra Gautum , Colella Joseph J.
Published: June 2020

Obesity and rapid weight loss after bariatric surgery is associated with the development of cholelithiasis and related complications. Several algorithms have been suggested in the management of the asymptomatic gallstones in patients presenting for weight loss surgery (WLS). Charts of patients presenting for laparoscopic Roux-en-Y (LRYGB) were retrospectively reviewed. Concomitant or delayed cholecystectomies were performed for symptomatic disease at the time of or after LRYGB, respectively. A total of 1376 patients underwent LRYGB and 21.0 per cent had a history of a cholecystectomy. An additional 2.7 per cent underwent cholecystectomy. The remaining 1050 “at-risk” patients were followed for a mean of 32.3 months and 4.9 per cent underwent delayed cholecystectomy for symptomatic disease. Of these patients, 88.5 per cent presented within 2 years of LRYGB. No significant morbidities were experienced by the “at-risk” cohort. Currently, there is no consensus in the treatment of asymptomatic cholelithiasis in patients presenting for WLS. A conservative regimen of reserving cholecystectomy for symptomatic disease is safe in patients undergoing LRYGB. Subsequent cholecystectomy was required in 4.9% with the majority of these patients presenting within 2 years of LRYGB. Further investigations in the form of randomized, prospective studies are necessary to clearly define the indications for cholecystectomy at the time of WLS.
Progressive Preoperative Pneumoperitoneum for Hernias with Loss of Domain
Authors: Mcadory R. Stephen , Cobb William S. , Carbonell Alfredo M.
Published: June 2020

Acting as a pneumatic tissue expander, progressive preoperative pneumoperitoneum (PPP) pressurizes the abdomen to prepare patients with giant hernias and loss of domain for hernia repair. We review our experience with PPP. Between 2006 and 2008, a prospective hernia database revealed nine patients who underwent PPP prior to hernia repair. Mean patient age was 54 years (41-68) and mean BMI was 31.3 kg/m2 (25.2-36.5). Patients had prophylactic vena cava filters and intraperitoneal catheters placed. Over a mean 22.4 days (7-64), patients received 7.6 (3-13) injections of air. PPP complications included death from pulmonary mycetoma (1), deep venous thrombosis and acute renal failure (1), port infection (1), kinked catheter requiring reoperation (1). Seven patients underwent successful hernia repair; open ventral (6) and laparoscopic inguinal (1). Defect size averaged 387 cm2 (110-980) with a mesh size of 420 cm2 (180-1200). Operative time averaged 256 minutes (175-330) with a mean blood loss of 157 ml (50-500). Post-hernia repair length of stay was 10.3 days (4-22). Hernia repair complications included ventricular tachycardia (1) and hernia recurrence (1). PPP has an acceptable risk, and for patients with large hernias and loss of domain, it may be a useful adjunct prior to definitive hernia repair.
Incremental Increases in Organ Retrieval after Protocol Driven Change in an Organ Procurement Organization: A 15-Year Assessment
Authors: Franklin Glen A. , Smith Jason W. , Daugherty Wendy , Threkeld Tom , Garrison R. Neal
Published: June 2020

The need for transplantable organs exceeds the available supply. Organ procurement organizations (OPOs) have undergone both voluntary and mandated changes to optimize available organs. The data from a single statewide OPO was reviewed from 1993 to 2008 and tracked with implementation of new protocols. During the study, 5548 organs were recovered with 4875 transplanted from 1441 donors (3.38 organs transplanted/donor (OTPD)). The conversion rate (CR) for consent rose from 42 to 72 per cent whereas the average age of donors increased from 33 to 45 years. After implementation of a family support liaison program, a higher performing hospital in the OPO realized an increase in CR from 57 to 97 per cent over 8 years. Implementation of an intensivist program improved OTPD. The number of standard criteria donors and extended criteria donors (ECD) increased. The increase in standard criteria donors yielded a large number of thoracic organs. ECD increased as did the organ discard rate from 8 to 16 per cent. Increases in organ retrieval were noted after incremental changes in OPO protocol. Family support and intensivist programs enhanced CR and OTPD. Increases in the number of ECD were noted with increasing age after the introduction of the intensivist program and an increase in transplant center use of these organs.
Vacuum-Pack Temporary Abdominal Wound Management with Delayed-Closure for the Management of Ruptured Abdominal Aortic Aneurysm and Other Abdominal Vascular Catastrophes: Absence of Graft Infection in Long Term Survivors
Authors: Ross Charles B. , Irwin Chance L. , Mukherjee Kaushik , Schumacher Paul M. , Dattilo Jeffery B. , Ranval Timothy J. , Guzman Raul J. , Naslund Thomas C.
Published: June 2020

Patients who undergo open repair of ruptured abdominal aortic aneurysms (rAAA) may require delayed abdominal wound closure to prevent the adverse consequences of intra-abdominal hypertension and abdominal compartment syndrome. However, surgeons may be reticent to use delayed abdominal closure techniques due to concern that such management may increase the risk of graft infection. We retrospectively reviewed our patient experience with rAAA and other vascular catastrophes in which vacuum-pack abdominal wound management with delayed closure was used between 2000 and 2007. Eighteen of 23 patients treated with delayed closure survived (78%). In five early deaths, graft infection was not clinically suspected. Sixteen of 20 rAAA patients survived, with abdominal wound closure achieved at a mean of 4 days. Mean follow up was 53 months, the longest among comparable series. Graft infection has not been encountered in this group. Our results suggest that the potential risk of graft infection should not outweigh the benefits of vacuum-pack temporary abdominal wound management with delayed closure in critically ill patients at high risk for intra-abdominal hypertension and abdominal compartment syndrome after major abdominal vascular procedures.