bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of Transarterial Chemoembolization Combined with Radiofrequency Ablation Therapy versus Surgical Resection for Early Hepatocellular Carcinoma
Authors: Yi Peng-Sheng , Huang Min , Zhang Ming , Xu Liangliang , Xu Ming-Qing
Published: June 2020

Both radiofrequency ablation (RFA) and surgical resection (SR) are radical treatment recommended for early hepatocellular carcinoma (HCC). Transarterial chemoembolization (TACE) is a palliative treatment for intermediate HCC, and TACE1RFA combined therapy is considered superior to TACE or RFA alone for management of early HCC. This systematic review compared the efficacy and safety of TACE1RFA combined therapy with SR for early HCC. Web of Science, PubMed, EMBASE, and the Cochrane Library were searched for literatures related with our topic. The primary endpoint was overall survival (OS), and the secondary endpoint was the recurrence-free survival (RFS) rate; safety was measured by the rate of major complications. The effect sizes of OS, RFS, and local progression rates were expressed by odds ratio (OR), while the effect size of complications was presented using relative risk. TACE1RFA combined therapy and SR had a similar 1-year OS rate [OR: 1.84; 95% confidence interval (CI): 0.82, 4.14; P > 0.05], 3-year OS rate (OR: 0.84; 95% CI: 0.43, 1.67; P > 0.05), 1-year RFS rate (OR: 0.77; 95% CI: 0.53, 1.11; P > 0.05), and 3-year RFS rate (OR: 0.88; 95% CI: 0.48, 1.42; P > 0.05) for early HCC. However, the 5-year OS rate (OR: 0.54; 95% CI: 0.40, 0.73; P < 0.05) and 5-year RFS rate (OR: 0.49; 95% CI: 0.27, 0.90; P < 0.05) were lower in patients with TACE1RFA than in those with SR. SR is associated with better long-term survival outcomes and a lower recurrence rate than TACE1RFA for patients with early HCC and is the optimal choice for patients with early HCC.
Inadequacy of Algorithmic Ventilator-Associated Pneumonia Diagnosis in Acute Care Surgery
Authors: Quick Jacob A. , Breite Matthew D. , Barnes Stephen L.
Published: June 2020

Clinical utility of algorithms to diagnose ventilator-associated pneumonia (VAP) in surgical patients has not been established. We aimed to test the diagnostic accuracy of two established methods to reliably diagnose VAP in acutely ill and injured surgical patients. After institutional review board approval, we prospectively collected data on 508 mechanically ventilated acute care surgery patients. Microbiologic samples were taken daily from all patients. Demographics, clinical, laboratory, and radiographic data were collected. The Johanson Criteria (JC) and Clinical Pulmonary Infection Score (CPIS) were calculated and analyzed. Sensitivity, specificity, and positive predictive values (PPV) and negative predictive value (NPV) were calculated in comparison to positive respiratory cultures. Of the 508 patients, 312 (61.4%) were acutely injured; emergent general surgery was performed in 141 (27.8%) patients, and 54 (10.6%) underwent elective operation. Positive respiratory cultures were identified in 198 (39%) of the 508 patients. JC diagnosed VAP in 291 (57.3%) patients (sensitivity 82.8%, specificity 59%, PPV 56.4%, NPV 84.3%, accuracy 68.3%). The CPIS resulted in 189 (37.2%) VAP diagnoses (sensitivity 61.1%, specificity 78.1%, PPV 64%, NPV 75.9%, and accuracy 71.5%). To address the inaccuracy of the algorithms, concordance testing was performed on the data to evaluate correlation between the algorithmic VAP diagnosis criteria and respiratory culture data. Nonconcordance with culture data diagnosis was identified with both JC (rho 0.41) and CPIS (rho 0.41). Sensitivity, specificity, PPV and NPV, and accuracy of both established clinical formulas was unacceptably low in acute care surgery patients.
Partial Nephrectomy for Nephroblastoma: A National Cancer Data Base Review
Authors: Richards Morgan K. , Goldin Adam B. , Ehrlich Peter F. , Beierle Elizabeth A. , Doski John J. , Goldfarb Melanie , Langer Monica , Nuchtern Jed G. , Vasudevan Sanjeev , Gow Kenneth W.
Published: June 2020

Standard of care for unilateral nephroblastoma includes total nephrectomy (TN) with nodal sampling. We sought to compare the outcomes of TN and partial nephrectomy (PN). We performed a retrospective cohort study of TN and PN for nephroblastoma using the National Cancer Data Base. The outcomes included nodal sampling frequency, margin status, and survival. Categorical and continuous data were evaluated with χ2 and t tests, respectively ( P < 0.05). Generalized linear models evaluated nodal sampling and margin status. Cox regression compared survival. In total, 235 patients underwent PN and 3572 had TN. TN patients were 50 per cent more likely to undergo nodal sampling (RR: 1.47, 95% CI 1.30–1.66). There was no difference in margin status (RR: 0.91, 95% CI 0.65–1.28) or overall survival (HR 1.57; 95% CI 0.78–3.19). This study reports the largest review of patients with PN for unilateral nephroblastoma. PN patients had less nodal sampling but similar margin involvement and overall survival.
Addition of Mesh Reinforcement for Pancreatic Stump and Braun Enteroenterostomy after Pancreaticoduodenectomy: A Single Institution Experience
Authors: Hua Jie , Meng Hongbo , He Zhigang , Yao Le , Sun Wei , Song Zhenshun
Published: June 2020

The morbidity rate after pancreaticoduodenectomy (PD) remains high and a modified digestive reconstruction may affect the postoperative complications. We investigated a new modification of PD by adding mesh reinforcement for the pancreatic stump and Braun enteroenterostomy with the aim of reducing postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE), respectively. From November 2010 to April 2015, 81 consecutive patients who underwent modified PD were retrospectively reviewed. The clinically relevant POPF and DGE rates were 4.9 and 6.1 per cent, respectively. The overall mortality rate was 2.4 per cent. The incidence of overall postoperative complications was 46.9 per cent, with 17.2 per cent considered as major complications (Clavien grades 3–5). The median postoperative length of hospital stay was 17 days (range 10–119 days). For patients who had major complications, median postoperative length of hospital stay increased significantly (22 vs 13 days, P = 0.001), as compared with those patients with no complications. The new modified digestive reconstruction after PD seems safe and reliable with low clinically relevant POPF and DGE rates. Further prospective controlled trials are essential to support these results.
Videoesophagography versus Endoscopy for Prediction of Intraoperative Hiatal Hernia Size
Authors: Tatum James M. , Samakar Kamran , Bowdish Michael E. , Mack Wendy J. , Bildzukewicz Nikolai , Lipham John C.
Published: June 2020

Magnetic sphincter augmentation is a novel surgical procedure for gastroesophageal reflux disease. Limited dissection at the hiatus is one of the benefits of the procedure, but makes precise and accurate preoperative assessment of even small hiatal hernia critical. Retrospective cohort study of 136 patients having undergone both endoscopy (EGD) and videoesophagography followed by operative assessment for hiatal hernia during magnetic sphincter augmentation. The objective of the study is to determine which preoperative modality more accurately predicts operative hiatal hernia size. Videoesophagography underestimated operative measurement by 0.37 ± 1.41 cm ( P = 0.003) and was less accurate in predicting intraoperative hiatal hernia size than EGD on linear regression analysis (β -0.729, SE 0.057, P < 0.001). EGD was less accurate at predicting hiatal hernia size as patient age increased (β -0.018, SE 0.007, P = 0.014) and with larger hernias (β -0.615, standard error (SE) 0.067, P < 0.001); however, endoscopic measurements did not differ significantly from intraoperative measurements (0.93 ± 1.23 cm vs 1.12 ± 1.43 cm, P = 0.12). EGD better predicts the size of small hiatal hernia measured during subsequent laparoscopic surgery.
Biomechanical and Histologic Evaluation of LifeMesh™: A Novel Self-Fixating Mesh Adhesive
Authors: Shahan Charles P. , Stoikes Nathaniel N. , Roan Esra , Tatum James , Webb David L. , Voeller Guy R.
Published: June 2020

Mesh fixation with the use of adhesives results in an immediate and total surface area adhesion of the mesh, removing the need for penetrating fixation points. The purpose of this study was to evaluate LifeMesh™, a prototype mesh adhesive technology which coats polypropylene mesh. The strength of the interface between mesh and tissue, inflammatory responses, and histology were measured at varying time points in a swine model, and these results were compared with sutures. Twenty Mongrel swine underwent implantation of LifeMesh™ and one piece of bare polypropylene mesh secured with suture (control). One additional piece of either LifeMesh™ or control was used for histopathologic evaluation. The implants were retrieved at 3, 7, and 14 days. Only 3- and 7-day specimens underwent lap shear testing. On Day 3, LifeMesh™ samples showed considerably less contraction than sutured samples. The interfacial strength of Day 3 LifeMesh™ samples was similar to that of sutured samples. At seven days, LifeMesh™ samples continued to show significantly less contraction than sutured samples. The strength of fixation at seven days was greater in the control samples. The histologic findings were similar in LifeMesh™ and control samples. LifeMesh™ showed significantly less contraction than sutured samples at all measured time points. Although fixation strength was similar at three days, the interfacial strength of LifeMesh™ remained unchanged, whereas sutured controls increased by day 7. With histologic equivalence, considerably less contraction, and similar early fixation strength, LifeMesh™ is a viable mesh fixation technology.
Level I Trauma Centers: More Is Not Necessarily Better
Authors: He Jack C. , Sajankila Nitin , Kreiner Laura A. , Allen Debra L. , Claridge Jeffrey A.
Published: June 2020

The optimal number of level I trauma centers (L1TCs) in a region has not been elucidated. To begin addressing this, we compared mortalities for patients treated in counties or regions with 1 L1TC to those with >1 L1TC across Ohio. Ohio Trauma Registry data from 2010 to 2012 were analyzed. Patients with age ≥15 from counties/regions with L1TC were included. Region was defined as a L1TC containing county and its neighboring counties. Two analyses were performed. In the county analysis, counties containing 1 L1TC were compared with counties with multiple L1TCs. This comparison is repeated on a regional level for the regional analysis. Subgroup analyses were performed. 38,661 and 55,064 patients were in the county and regional analysis, respectively. Patients treated in counties or regions with multiple L1TCs were significantly younger ( P < 0.001). Despite this, the mortality was similar for the two groups in the county analysis and significantly higher for regions with multiple L1TCs ( P < 0.001). Multivariate logistic regression demonstrated that having multiple L1TC coverage in a region was an independent predictor for death (odds ratios: 1.17; 1.07-1.28; P = 0.001). Subgroup analyses showed that mortality in counties and regions with multiple L1TCs was not lower in any subgroups but was higher in patients with age ≥65 and patients with blunt injuries ( P < 0.05). Having multiple L1TCs in a county was associated with increased mortality in certain patient subgroups. Having multiple L1TCs in a region was an independent predictor for death. These results should be considered carefully when designing future regionalized trauma networks. More L1TCs is not necessarily better.
The Development of Extracorporeal Membrane Oxygenation
Authors: Nakayama Don K.
Published: June 2020

Evolving from the development of heart-lung machines for open-heart surgery, extracorporeal membrane oxygenation has reemerged as a rescue modality for patients with acute respiratory failure that cannot be supported by conventional modes of ventilation. The history of extracorporeal membrane oxygenation begins with the discovery of heparin, fundamental to the success of extracorporeal circulation and membrane lungs. Engineers and scientists created suitable artificial membranes that allowed gas exchange while keeping gas and blood phases separate. Special pumps circulated blood through the devices and into patients without damage to delicate red cells and denaturing plasma. Initial attempts in adults ended in failure, but Robert Bartlett, first at Loma Linda, CA, then at Ann Arbor, MI, succeeded in applying the technology in newborn infants with persistent pulmonary hypertension. Preserved in the critical care of infants, the technology in time could be reapplied in the life support of older children and adults.
Narcotic-Dependent Patients Derive Equal Benefit from Enhanced Recovery
Authors: Ross Julia , Fogel Sandy
Published: June 2020

Areas of the southeast United States have endemic levels of prescription drug use, diversion, and abuse. Because preoperative narcotics use is associated with increased surgical morbidity and increased readmission rates, there is a compelling need to categorize health outcomes of patients maintaining an active opioid prescription. The purpose of this study is to determine the health outcomes of preoperative narcotic users who undergo colorectal surgery within the enhanced recovery (ER) protocol, a set of multimodal interventions designed to reduce postoperative complications. Five hundred and five colorectal surgery patients were identified within the ER protocol at Carilion Clinic. Opioid dependence was defined as an active prescription for 30 days before surgery. Thirty-day outcome variables were defined by the National Surgical Quality Improvement Program. One hundred and one patients were identified as opioid dependent and 404 as opioid naïve. Groups were comparable in terms of age at surgery, mean body mass index, and presurgical physical classification. Groups fared similarly with regard to readmission (χ2, P > 0.999), reoperation (χ2, P = 0.869), and average length of stay [t(135) = 1.49, P = 0.137]. These preliminary data show that opioid-dependent patients derive benefit equal to opioid-naïve patients within the ER protocol.
Hospital-Based Study of Compliance with NCCN Guidelines and Predictive Factors of Sentinel Lymph Node Biopsy in the Setting of Thin Melanoma Using the National Cancer Database
Authors: Hayek Sarah A. , Munoz Amanda , Dove James T. , Hunsinger Marie , Arora Tania , Wild Jeffrey , Shabahang Mohsen , Blansfield Joseph
Published: June 2020

Thin melanoma is the most common form of melanoma in the United States. The National Comprehensive Cancer Network (NCCN) has guidelines for sentinel lymph node biopsy (SLNB) which recommend “discuss and consider” SLNB for invasion >0.75 mm and “discuss and offer” SLNB for invasion >0.75 mm with suspicious features. This study looked at compliance with NCCN guidelines and factors that are predictive of a positive SLNB. This is a retrospective study of patients diagnosed with thin melanoma 2012–2013 using the National Cancer Database. A total of 26,456 patients met study qualifications. Univariate analysis showed that 76 per cent of patients meeting criteria underwent SLNB. Patients recommended to “discuss and consider” received SLNB 53 per cent of the time and those not recommended for SLNB received SLNB 20 per cent of the time. On multivariate analysis, depth was not predictive for positive SLNB whereas mitoses and ulceration were. Other factors predictive of positive SLNB were nodular cell type, lymphovascular invasion, and Clark's level greater than or equal to IV. Patients with thin melanoma that meet NCCN guidelines for SLNB undergo this procedure in good compliance but those who do not meet criteria continue to receive SLNB. Positive predictive factors for positive SLNB include mitoses, ulceration, Clark's level, and primary site.
Chest Wall Stabilization Leads to Shortened Chest Tube Stay Time in Rib Fracture Patients after Traumatic Chest Wall Injury
Authors: Fitzgerald Michael T. , Ashley Dennis W. , Abukhdeir Hesham , Christie D. Benjamin
Published: June 2020

Rib fixation has become a strategy for patients with displaced rib fractures and hemo/ pneumothoraces (HTX/PTX). Rib plating improves pain control and respiratory mechanics, thereby reducing recovery times and morbidity/mortality. Current treatment consists of chest tube placement, pain control, and pulmonary toilet. The addition of rib plating should reduce time till HTX/PTX resolution and chest tube removal. The study compares chest tube stay time in ribplated patients with those managed with current treatment. We hypothesize that patients undergoing rib plating will have a reduction in chest tube stay times. A retrospective review of a Level 1 trauma registry was performed. Rib-plated patients (n = 70) from 2013 to 2015 were compared with a randomly selected, nonoperative, injury-matched, historical (2003–2008) control group (n = 60). Demographics were obtained. Independent variables analyzed include Injury Severity Score (ISS), intensive care unit days, length of stay, and chest tube stay times. 60 control patients had an average ISS of 19 and age of 51 years, compared with ISS of 20 and age of 56 years in plated patients. Plated patients had a reduction in chest tube days, 6.5 versus 8.4 days, P value = 0.02. Plated patients had 14 intensive care unit days versus 19 days, P value = 0.09. T tests were performed to confirm significance. Reduction in chest tube days improves patient pain and allows for improved ambulation and pulmonary toilet, helping reduce respiratory complications. Our review shows that plating may prove beneficial in reducing complications associated with management of HTX/PTX in the setting of rib fractures.
Colon and Rectal Neuroendocrine Tumors: Are They Really One Disease? A Single-Institution Experience over 15 Years
Authors: Broecker Justine S. , Ethun Cecilia G. , Postlewait Lauren M. , Le Nina , Mcinnis Mia , Russell Maria C. , Sullivan Patrick , Kooby David A. , Staley Charles A. , Maithel Shishir K. , Cardona Kenneth
Published: June 2020

Colon and rectal neuroendocrine tumors (NETs) are often studied as one entity. Recent evidence suggests that worse outcomes are associated with colon compared with rectal NETs; direct comparisons are lacking. Our aim was to assess clinicopathologic, treatment, and survival differences between these diseases. All patients who underwent resection of colorectal NETs at one institution from 2000 to 2014 were included and analyzed. Of 29 patients, 12(41%) had colon and 17 (59%) had rectal NETs. Baseline demographics were similar between groups, although colon patients tended to be symptomatic at presentation (67% vs 44%, P = 0.41). Eighty-three per cent of colon patients underwent surgical resection, whereas 77 per cent of rectal patients underwent endoscopic or transanal resection ( P = 0.003). Colon patients had larger (3.4 cm vs 0.7 cm, P = 0.03), higher T-stage (T3/T4: 91% vs 14%, P = 0.003), higher grade tumors (42% vs 12%, P = 0.09) with more lymph nodes (58% vs 24%, P = 0.12) and lymphovascular invasion positivity (58% vs 24%, P = 0.32). Five-year disease-specific survival was 53% versus 80 per cent for colon and rectal patients, respectively ( P = 0.22). After excluding high-grade tumors, colon NETs were associated with lymphovascular invasion positivity (100% vs 17%, P = 0.05) and advanced T-stage (80% vs 8%, P = 0.01). Colon and rectal 5-year disease-specific survival was 67 versus 80 per cent ( P = 0.86). Colon and rectal NETs clinically seem to be distinct entities. Colon tumors have more aggressive clinicopathologic features, which may translate to worse outcomes. These differences in tumor biology may demand distinct management and should be further studied in a multi-institutional setting.
Improved Intraoperative Communication after Utilization of Navigational Grids during Laparoscopic Cholecystectomies
Authors: Goff Tyler , Cull John D.
Published: June 2020

Efficient intraoperative communication (IC) between an attending and resident during surgery is highly valuable. Few tools, however, have been developed to improve IC. This study evaluates IC between residents and attendings after utilization of a navigational grid (NG) during laparoscopic cholecystectomies. Attendings and surgery residents completed a 10-question survey after performing a laparoscopic cholecystectomy. Surveys were collected for 12 weeks: six weeks before use of NGs and six weeks with use of NGs. The NGs were constructed to fit our 26”-surgical monitors and allowed the monitors to be divided into a 7 x 4 grid. Hunderd and fifteen surveys were collected: 50 from attendings (pre-NG: 31 vs NG: 19) and 65 from residents (42 vs 23). Before NGs, attendings were less likely than residents to perceive attending instructions to be clear (64.5 vs 93.0%, P = 0.0001) and less likely to believe IC left little room for confusion during the procedure (64.5 vs 90.5%, P = 0.007). After NGs, attendings believed intraoperative directional guidance was more concise and clear (64.5 vs 89.5%, P = 0.062); they also reported that NGs left little room for IC confusion during the procedure (64.5 vs 94.7%, P = 0.039). Surveys showed the grid's utility to be inversely correlated with years of experience. Residents (<two years) and attendings (<10 years) with less experience had the highest median in reported usefulness (7 out of 10). Our findings show that NGs can be a useful tool for improving IC, especially in residents and attendings with less experience.
How Technology Shaped Modern Surgery
Authors: Nakayama Don K.
Published: June 2020

The history of endoscopy and minimally invasive surgery is the story of technological advances in illumination, optics, and imaging that allowed operations to be performed within the body. After invention of the incandescent bulb by Joseph Swan and Thomas Edison in 1879, the basic design of early cystoscopes remained unchanged during the first half of the 20th century. Three inventions made endoscopy and laparoscopy possible. Invented in the 1950s, the Hopkins glass rod lens system was so elegant and effective—it gave images 80 times better than traditional Galilean optics—that endoscopes of the same design remain in use today. Also, originating in the same decade, fiber optics had in turn two major contributions: Flexible endoscopy and the transfer of light from a high voltage source into the body to illuminate internal structures and organs. Solid-state camera technology, developed in the late 1970s and 1980s, gave images of exceptional detail from a camera chip at the eyepiece of an endoscope. The panorama of advances created by the same technologies—global telecommunications, cellphone cameras, images from interplanetary space probes—reveals endoscopy and laparoscopic surgery as two more examples of today's technological age.
The Impact of Ostomy Creation after Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy in a Newly Established Peritoneal Malignancy Program
Authors: Stiles Zachary E. , Hinkle Nathan M. , Munene Gitonga , Dickson Paxton V. , Davidoff Andrew M. , Deneve Jeremiah L.
Published: June 2020

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has improved outcomes for selected patients with peritoneal carcinomatosis and often requires ostomy creation. We examined the impact of ostomy creation in a newly established peritoneal malignancy program. A retrospective review was performed of CRS-HIPEC procedures from 2011 to 2016. Those who did and did not receive an ostomy were compared. Fifty-eight patients underwent CRS-HIPEC and an ostomy was created in 25.9 per cent. Median peritoneal cancer index (14 vs 16, P = 0.63) and multivisceral resection rates (87.9 vs 100.0%, P = 0.17) were similar between groups. Multivariable analysis revealed that bowel resection (OR 210.65, P = 0.02) was significantly associated with ostomy creation. Advanced age was noted to be inversely associated with stoma formation (OR 0.04, P = 0.04). Progression-free survival was significantly lower in the ostomy group (18 vs 23 months, P = 0.03). Those with an ostomy experienced prolonged length of stay (13.3 ± 7.4 vs 9.5 ± 3.7, P = 0.01). At follow-up, 6/10 temporary ostomies had undergone reversal and three patients experienced morbidity after reversal. Ostomy creation may occur during CRS-HIPEC and carries potential for morbidity. Ostomy creation may contribute to postoperative length of stay. Patients should be counseled preoperatively on the potential impact of ostomy placement during CRS-HIPEC.
Utilizing Surgical Bootcamps to Teach Core Entrustable Professional Activities to Senior Medical Students
Authors: Heimroth Jamie , Jones Victoria M. , Howard Jeffrey D. , Sutton Erica R.H.
Published: June 2020

To promote residency preparedness, the Association of American Medical Colleges defined 13 core entrustable professional activities for entering residency (CEPAERs), which represent tasks that students should be able to perform on day one of residency. At the authors’ institution, a four-week surgery boot camp course is offered to senior medical students, which may provide an effective mechanism for teaching the CEPAERs. Nine senior students participating in a surgery boot camp course were subjected to pre- and post-course surveys. Student expectations were closely aligned with the CEPAERs. Competence was demonstrated in all CEPAERs; however, four students did require remediation with Advanced Cardiovascular Life Support before achieving competence. In the “death on the wards module,” we found a significant increase in student confidence (19.78, SD 1.47, P > 0.05 vs 31.56, SD 1.49, P < 0.01) and knowledge (16.11, SD 1.32, P > 0.05 vs 31.33, SD 2.04, P < 0.01). In a one-year follow-up survey, all participants agreed that the boot camp course was useful and positively impacted their intern year. Surgical boot camp courses provide an effective and reproducible means for teaching the CEPAERs and was found useful in preparing medical students for residency.
Mild to Moderate to Severe: What Drives the Severity of ARDS in Trauma Patients?
Authors: Daher Pamela , Teixeira Pedro G. , Coopwood Thomas B. , Brown Lawrence H. , Ali Sadia , Aydelotte Jayson D. , Ford Brent J. , Hensely Adam S. , Brown Carlos V.
Published: June 2020

Acute respiratory distress syndrome (ARDS) is a complex inflammatory process with multifactorial etiologies. Risk factors for its development have been extensively studied, but factors associated with worsening severity of disease, as defined by the Berlin criteria, are poorly understood. A retrospective chart and trauma registry review identified trauma patients in our surgical intensive care unit who developed ARDS, defined according to the Berlin definition, between 2010 and 2015. The primary outcome was development of mild, moderate, or severe ARDS. A logistic regression model identified risk factors associated with developing ARDS and with worsening severity of disease. Of 2704 total patients, 432 (16%) developed ARDS. Of those, 100 (23%) were categorized as mild, 176 (41%) as moderate, and 156 (36%) as severe. Two thousand two hundred and seventy-two patients who did not develop ARDS served as controls. Male gender, blunt trauma, severe head and chest injuries, and red blood cell as well as total blood product transfusions are independent risk factors associated with ARDS. Worsening severity of disease is associated with severe chest trauma and volume of plasma transfusion. Novel findings in our study include the association between plasma transfusions and specifically severe chest trauma with worsening severity of ARDS in trauma patients.
Optimizing Nutrition for the Surgical Patient: An Evidenced Based Update to Dispel Five Common Myths in Surgical Nutrition Care
Authors: Hartwell Jennifer L. , Cotton Ann , Rozycki Grace
Published: June 2020

Traditional practices in the delivery of nutrition to the surgical patient include reliance on nonspecific laboratory markers to define malnutrition, prolonged periods of nil per os, early and liberal initiation of parenteral nutrition, withholding enteral feedings based on gastric residual volume measurements, and pursuing feeding tube access for most patients unable to take oral nutrition. However, recent studies call into question all of these practices. This review aims to provide evidenced-based support to abandon these myths regarding nutrition delivery and offer practical up-to-date advice for best practices in patient care.
Delayed Healing Associated with Silver Sulfadiazine Use for Partial Thickness Scald Burns in Children
Authors: Raymond Steven L. , Zecevic Antonia , Larson Shawn D. , Ruzic Ana , Islam Saleem
Published: June 2020

Burns are a leading cause of injury in children. Management principles vary widely, with no consensus about the best treatment. The purpose of this study was to compare outcomes of three different dressings for pediatric partial-thickness scald burns. A retrospective, single-center study was conducted for patients 0–16 years old with a diagnosis of acute partial-thickness scald burn between July 2007 and December 2012. Data regarding prehospital, inpatient, and outpatient course were collected. Cohort was stratified into topical antimicrobial (TA) ointment, silver sulfadiazine (SS), and biosynthetic dressing (BD) groups for analysis. The primary outcome of interest was time to full healing. One hundred and seventy-seven patients met all study criteria. Overall, mean total body surface area burned was 8.3 per cent. TAwas used in 24 per cent cases, SS in 32 per cent, and BD in 44 per cent. The groups were comparable in terms of presenting burn characteristics and hospital course with the exception of the BD group being associated with greater extent of injury. Patients treated with SS had a significantly longer time to full healing and increased requirement of compression garments for scar therapy. Based on these data, the authors have amended their practice and presently use BD or TA dressings to improve healing.
When Minutes Fly by: What is the True “Golden Hour” for Air Care?
Authors: Duke Marquinn , Tatum Danielle , Sexton Kevin , Stuke Lance , Robertson Ronald , Sutherland Michael , Tyroch Alan , Agrawal Vaidehi , Duchesne Juan
Published: June 2020

Air transport was developed to hasten patient transport based on the “golden hour” belief that delayed care leads to poorer outcome. The primary aim of our study was to identify the critical inflection point of increased nonsurvivors on total prehospital time. This was a multicenter review of adult trauma patients transported by air between November 2014 and August 2015. Primary outcome of interest was all-cause inhospital mortality. Total helicopter emergency medical services times of nonsurvivors were plotted to visualize the distribution of prehospital time. Of 636 patients included, 71 per cent were male and 86 per cent suffered blunt trauma. Among non-survivors, mortality doubled once total helicopter emergency medical services time exceeded 30 minutes (P < 0.001). Nonsurvivors presented with significantly lower median [interquartile range (IQR)] Glasgow Coma Score compared with survivors [3 (3–13) vs 15 (12–15), respectively; P < 0.001] as well as a significantly higher median (IQR) Injury Severity Score [26 (19–41) vs 12 (5–22); P < 0.001], increased incidence of penetrating mechanism of injury [21 vs 8%; P = 0.002], and higher median (IQR) shock index [0.84 (0.63–1.06) vs 0.71 (0.6–0.87); P = 0.023]. We identified an inflection point of doubling in mortality after 30 minutes. This suggests a possible threshold effect between time and mortality in severely injured patients. Revised field criteria for determining which injured patients would most benefit from helicopter transport are needed.
Incisional Hernia in Renal Transplant Recipients: A Systematic Review
Authors: Simson Nick , Samuel Parker , Stonier Thomas , Halligan Stephen , Windsor Alastair
Published: June 2020

Incisional hernia follows midline laparotomy in 8 to 20 per cent of cases, but the rate following lateral incision is not well documented. This systematic review summarizes incisional hernia rate after open renal transplant. We searched EMBASE, MEDLINE, and the Cochrane Library databases from January 2000 to November 2016 inclusive. The outcomes included in our analysis were the posttransplant incisional hernia rate, significant patient risk factors for incisional hernia, the definition of incisional hernia used, the method used to detect incisional hernia, and the incision used for transplantation. Eight retrospective case series were identified, three describing renal transplant recipients and five describing incisional hernia repairs postrenal transplant. All reported the incisional hernia rate postrenal transplant at the host institution. The hernia rate ranged from 1.1 to 7.0 per cent, with a mean of 3.2 per cent. Factors associated with incisional hernia were body mass index >30, age >50, cadaveric graft, and reoperation through the same incision. Despite the significant comorbidity of renal transplant recipients, the incisional hernia rate postrenal transplant is significantly lower than that of post-midline laparotomy. The reasons for this are discussed. This demonstrates the importance of operative technique, local tissue quality and biomechanical factors in the formation of incisional hernia.
Early Closure of Infected Laparotomy Wound with Negative-Pressure Wound Therapy: Safety and Efficacy in 42 Consecutive Cases
Authors: Bi Hongda , Li Junhui , Xue Chunyu , Marks Malcolm
Published: June 2020

Postoperative surgical site infections (SSIs) are one of the most common complications. SSIs after laparotomy have a high incidence and are complicated and expensive to heal. The aim of this study was to evaluate the safety and efficacy of a novel therapy of early closure of open abdominal SSIs wound combining wound irrigation with negative pressure wound therapy (NPWT). Open abdominal SSIs wounds were closed with sutures in 42 consecutive patients. Topical NPWT was applied over a closed wound with a deep drain to allow dynamic drainage and wound irrigation. CT scan with contrast medium injected through the deep drain was performed in patients with suspicious tracts detected during debridement surgery three days after surgery to identify a potential fistula. Wound healing and safety of the therapy was evaluated during an average six months follow-up. Closed wounds healed successfully in all the patients without recurrence of wound infection. Fistulas were easily diagnosed in all four fistula patients by using CTscan with contrast medium injection through the wound. Fistula was confirmed in these four patients at re-exploration. All the drain tube wounds healed spontaneously after drain removal. No severe adverse event occurred during therapy in any patients. With the aid of topical NPWT and deep drainage and irrigation, early closure of open SSIs wound can be done safely. We were also able to diagnose gastrointestinal fistulas at an early stage with the use of CTscan imaging after contrast injection into the wound.
Initial Experience with Fibrin Glue Treatment of Anal Fistulae in Children
Authors: Liao Fan-Ting , Chang Chi-Jen
Published: June 2020

Pediatric anal fistulae commonly result from recurrent perianal abscesses, of which nearly 50 per cent develop an anal fistula. The purpose of this study was to report the results of using fibrin glue to treat anal fistula in pediatric patients. Infants and children with recurrent perianal abscesses and anal fistulae were treated with either fistulectomy or fibrin glue. Demographic and clinical characteristics and outcomes were compared between the groups. A total of 34 children were included; 27 received fistulectomy (median age eight months) and seven received fibrin glue treatment (median age 14 months). No significant differences in demographic or clinical characteristics were found between the two groups (all, P > 0.05). Median follow-up duration was significantly higher in the fibrin glue group compared with that in the fistulectomy group (five months vs one month, P = 0.003). There was one recurrence in the fistulectomy group, and no recurrences in the fibrin glue group (P = 1.0). No complications occurred in either group. Fibrin glue treatment is a simple and effective treatment alternative in the management of anal fistula in children, offering the advantage of sphincter muscle-sparing and reduced risk of fecal incontinence.
One More Time: Redo Paraesophageal Hernia Repair Results in Safe, Durable Outcomes Compared with Primary Repairs
Authors: Kao Angela M. , Otero Javier , Schlosser Kathryn A. , Marx Julia E. , Prasad Tanushree , Colavita Paul D. , Heniford B. Todd
Published: June 2020

The incidence and causes of failed paraesophageal hernia repairs (PEHR) remain poorly understood. Our study aimed to evaluate long-term clinical outcomes after reoperative fundoplication as compared with initial PEHR. A prospectively maintained institutional hernia-specific database was queried for PEHR between 2008 and 2017. Patients with prior history of PEHR were categorized as “redo” paraesophageal hernia (RPEH). Primary outcomes included postoperative morbidity, mortality, symptom resolution, and hernia recurrence. A total of 402 patients underwent minimally invasive PEHR (Initial PEH = 305, RPEH = 97). Redo PEHR had more prevalent preoperative nausea/vomiting (50.6% vs 34.1%, P < 0.007) and weight loss (24.1% vs 13.5%, P < 0.02). RPEH had had longer mean operative time (256.4 ± 91.2 vs 190.3 ± 59.9 minutes, P < 0.0001) and higher rate of conversion to open (10.3% vs 0.67%, P < 0.0001); however, no difference was noted in postoperative complications, hernia recurrence, or mortality between cohorts. Laparoscopic revision of prior PEHR in symptomatic patients can be safely performed with favorable outcomes compared with initial PEHR. Despite redo procedures seeming to be more technically demanding (as noted by longer operative time and higher conversion rates), outcomes are similar and overall resolution of symptoms is achieved in most patients.
Gastroduodenal Surgery: A Persistent and Continuing Challenge
Authors: Melmer Patrick D. , Banks Trenton , Holmes Sharon , Sciarretta Jason D. , Davis John Mihran
Published: June 2020

The number of patients being treated surgically for gastroduodenal disease has decreased over the past five decades as a result of focus on medical treatment. However, perforated and bleeding peptic ulcer disease (PUD) continues to represent a significant percentage of patients who require emergency surgery. The aim of this study was to characterize these critically ill surgical patients treated for gastroduodenal disease in our hospital. A retrospective, single-center, consecutive cohort study of all patients identified from the hospital National Surgical Quality Improvement Program database who were admitted to our institution requiring emergent surgical intervention over the past two years was conducted. Of 423 patients, 33 (7.8%) had operative procedures for complications of PUD, of which 19 patients (57.6%) had perforation; nine patients (27.3%) had hemorrhage; one patient (3.0%) had both perforation and hemorrhage; two patients (6.1%) had distal gastrectomies for ulcers refractory to medical management alone, and two patients (6.1%) had gastrectomies for malignant gastric neoplasms. There is a significant population of patients who present with life-threatening complications of PUD, despite the decline in PUD worldwide. These patients are critically ill and require careful and diligent management for good outcomes.
Emergency General Surgery—A Misnomer?
Authors: Quinn Kirby , Davis Mary E. , Carter Lewin , Shortell Cynthia K. , Sommer Courtney
Published: June 2020

Emergency general surgery (EGS) is defined as the urgent assessment and treatment of non-trauma, general surgical emergencies involving adults. Acute surgical emergencies often represent the most common reason for hospital admission with diagnoses, including bowel obstruction and appendicitis. EGS is a growing surgical subspecialty that includes both operative and nonoperative management of acutely ill patients. We sought to assess the burden of nonoperative care in EGS patients at our academic medical center. This study was conducted by retrospective analysis of prospectively collected data from patients entered into the Duke EGS Registry between July 1, 2016 and September 10, 2017. Fifty-six per cent (n = 771) of patients in the Duke EGS Registry (n = 1377) were managed nonoperatively as compared with 44 per cent (n = 606) who were managed operatively. Nonoperative management of disease represents a large subset of EGS and, therefore, needs further investigation to improve processes, outcomes, and standardization of care.
Factors Contributing to Morbidity after Combined Arterial and Venous Lower Extremity Trauma
Authors: Manley Nathan R. , Magnotti Louis J. , Fabian Timothy C. , Cutshall Michael B. , Croce Martin A. , Sharpe John P.
Published: June 2020

The purpose of this study was to evaluate the impact of management of venous injury on clinical outcomes in patients with combined lower extremity arterial and venous trauma. Patients with common and external iliac, common and superficial femoral, and popliteal artery injuries were identified. Patients who underwent vein repair and those who received vein ligation were compared. The analysis was repeated for those patients who required secondary intervention for their arterial injury and those who did not require secondary intervention. Seventy patients were identified with both arterial and venous injuries: 40 underwent vein ligation and 30 received vein repair. There was no difference in ischemic time between patients undergoing vein repair compared with ligation. Vein ligation did not produce a higher incidence of muscle debridement (10% vs 15%, P = 0.72), necessity for secondary intervention (10% vs 7.5%, P = 0.99), or amputation (3.3% vs 7.5%, P = 0.63). Patients who required secondary intervention had a greater degree of shock on presentation (packed red blood cells (PRBC), 13 units vs 6 units, P = 0.02) and were more likely to require muscle debridement (50% vs 9%, P = 0.02) and amputation (33% vs 3%, P = 0.03). Vein ligation did not impact muscle ischemia or success of arterial repair in patients with combined venous and arterial trauma in the lower extremities. Patient morbidity after extremity vascular trauma is most related to degree of shock.
Use of Telemedicine in Surgical Education: A Seven-Year Experience
Authors: Marttos Antonio C. , Juca Moscardi Mariana Fernandes , Alvim Fiorelli Rossano Kepler , Pust Gerd Daniel , Ginzburg Enrique , Schulman Carl Ivan , Grant April Anne , Namias Nicholas
Published: June 2020

Uniformity in surgical education is challenging because surgical experience is based on rotation assignments. With work hour restrictions, the likelihood of residents being exposed to rare or unusual cases is diminished. Telemedicine may create a new learning paradigm for surgical education and supplement exposure for rare or unusual cases. A retrospective review (2010–2016) of teleconferences involving trauma centers worldwide was conducted. Participating hospitals included centers from underdeveloped countries to first world nations. Trauma cases were discussed among surgeons with different levels of experience and resource availability. Data collected included types of cases, anatomic injury patterns, hospital location, and the number of telemedicine centers and viewers participating. Seventy-three hospitals in 64 cities, spanning 27 countries, participated in 276 telemedicine grand round conferences. Cases discussed included penetrating trauma (47%), blunt trauma (42%), and blast injury (4%). The anatomic regions included were the thorax (28%), abdomen (26%), thoracoabdominal region (13%), neck (7%), and pelvis (6%). The most common injury discussed was vascular in nature (18%), followed by the lung, liver, diaphragm, and heart. The most common vascular lesion was in the aorta (18%), followed by the iliac vessels (8%) and the vena cava (7%). Telemedicine is a valuable tool, allowing the dissemination of diverse experiences. Most cases presented evaluated rare injuries or complex surgical approaches, which are not commonly seen on trauma sites. Learning different approaches in the management of complex trauma will make surgeons more prepared to deal with challenging cases.
Recurrence Patterns after Primary Excision of Invasive Melanoma with Melanoma in situ at the Margin
Authors: Oh Grace , Farley Clara R. , Lopez-Aguiar Alexandra G. , Russell Maria C. , Delman Keith A. , Lowe Michael C.
Published: June 2020

The significance and management of melanoma in situ (MIS) at the margin of excision of invasive melanoma is debated. Patients undergoing excision of invasive melanoma from 2000 to 2016 with MIS at the margin were identified. A cohort without MIS was matched for age, gender, location, and Breslow depth. Thirty-two patients with 33 cases of MIS at the margin were identified. Melanoma was located on the head/neck (66.7%), extremities (24.2%), and trunk (9.1%). Median Breslow depth was 1.0 mm (range 0.25–10.80). Margin treatment included re-excision (45.5%), re-excision plus imiquimod (3.0%), imiquimod alone (9.1%), and observation alone (42.4%). At a median follow-up of 91 months (range 28–126), five patients (15.2%) with a median Breslow depth of 4.75 mm (range 1.10–6.70) developed local recurrence (LR). Three underwent re-excision of the positive margin and two were observed. Intervention for positive margins did not decrease LR compared with observation (P = 0.905, OR = 1.125, 95% confidence interval [CI] 0.162–7.824). All five patients with LR were alive at the last follow-up. There were two recurrences in the matched cohort (6.1%); both were alive at the last follow-up. Risk of LR is higher with MIS at the margin, but this does not seem to impact survival. Larger studies may elucidate predictive factors and interventions that decrease risk for LR.
Propofol Infusion Syndrome: Efficacy of a Prospective Screening Protocol
Authors: Schroeppel Thomas J. , Clement L. Paige , Barnard Danielle L. , Guererro Whitney , Ferguson Margaret D. , Sharpe John P. , Magnotti Louis J. , Croce Martin A. , Fabian Timothy C.
Published: June 2020

Propofol infusion syndrome (PIS) is a potentially lethal complication of propofol marked by rhabdomyolysis, metabolic acidosis, and cardiac arrhythmias or collapse. The objective of this study was to determine the effectiveness of a prospective screening protocol to prevent PIS. All trauma patients admitted who received propofol as a continuous infusion were prospectively screened from November 1, 2013 to December 31, 2015. Variables studied included demographics, injury severity, laboratory values, infusion rates, and mortality. Serum creatine phosphokinase (CPK) and lactate were drawn daily. Propofol was stopped for a positive screen defined as an increase in CPK to greater than 5000 IU/L or lactate greater than 4 mmol/L. Positive and negative cohorts were compared. Two hundred and twenty-five patients met the inclusion criteria and 12 patients (5.3%) had propofol stopped because of elevated CPK. No differences were identified in demographics, transfusions, injury severity, hospital length of stay, or propofol dose. The positive screened group had longer intensive care unit length of stay (20 vs 13 days; P = 0.002) and increased vent days (14.5 vs 10 days; P = 0.008). Max serum osmolality (334 vs 305 mosm/kg; P = 0.049) and max serum CPK (6782 vs 1058 IU/L; P < 0.0001) were higher in the positive cohort. No cases of PIS occurred, and mortality (16.7 vs 15.5%; P = 0.999) was not different between the cohorts. The screening protocol was effective in eliminating PIS. Serial CPK evaluations provided an effective screening tool and serum lactate can be dropped from screening.