bluuebunny/crossref_metadata_2025 huggingface dataset:
Tumoral Pseudoangiomatous Stromal Hyperplasia of the Breast
Authors: Wieman Stephanie M. , Landercasper Jeffrey , Johnson Jeanne M. , Ellis Richard L. , Wester Susan M. , Lambert Pamela J. , Ross Lauren A.
Published: June 2020

Tumoral pseudoangiomatous stromal hyperplasia (PASH) is a rare benign proliferative disease of the breast. The majority of the literature reports of PASH have not contained detailed descriptions of the imaging characteristics of PASH. A 10-year retrospective study of patients with tumoral PASH and a 20-year Ovid MEDLINE® search were performed to determine whether specific imaging and needle biopsy results could characterize PASH preoperatively. We identified 22 patients with tumoral PASH. Seventeen (77%) of 22 women had a palpable lump and 14 (72%) of 21 had a density on mammography. Ultrasound (US) findings included mixed or hypoechoic echogenicity in 83 per cent and ill-defined borders in 62 per cent. Eight (36%) patients had lesions with a Breast Imaging Reporting and Data System (BI-RADS®) classification of 4 or 5. The sensitivity of preoperative core needle biopsy (CNB) to identify PASH was 83 per cent. A review of the literature revealed that 90 per cent of patients with PASH had some malignant imaging characteristics and 95 per cent had a mass on mammography. The imaging characteristics of PASH exhibited marked variability. Excision of PASH after CNB may be considered for patients with symptoms, enlarging lesions, or lesions classified as BI-RADS® 4 or 5. PASH diagnosed by CNB allows selected patients to avoid excision.
Successful Completion of Neoadjuvant Chemoradiation and Surgical Resection for Esophageal Cancer after Perforation: A Case for Endoscopic Stenting
Authors: Hernandez Jonathan M. , Barthel James S. , Kelley Scott T.
Published: June 2020

Iatrogenic esophageal perforation during endoscopy in the setting of malignancy is an uncommon but often devastating complication and presents a formidable challenge to the surgeon. We sought to determine the efficacy of a self-expanding plastic stent for esophageal perforation before neoadjuvant chemoradiation in a single patient. A 74-year-old woman with a T4N0 adenocarcinoma at the gastroesophageal junction was perforated during upper endoscopy. We elected to manage the perforation with a silicone-covered, self-expanding Polyflex® stent. Subsequent studies revealed good positioning of the stent with exclusion of the perforation from the esophageal lumen. The patient subsequently underwent neoadjuvant chemoradiation therapy with cisplatin, 5-flourouracil, and external beam radiation (2640 Gy) followed by minimally invasive, hand-assisted transhiatal esophagogastrectomy. We describe the first case of endoscopic stenting for locally advanced, perforated esophageal cancer for the purposes of administering neoadjuvant chemoradiation as a bridge to definitive surgery. This patient was able to resume oral nutrition after stenting and during neoadjuvant therapy, experiencing no major complications from chemoradiation. Chemoradiation does not necessarily preclude the use of endoscopically placed covered plastic esophageal stents as a bridge to resection, even in the face of iatrogenic perforation.
Enterocutaneous Fistula Complicating Trauma Laparotomy: A Major Resource Burden
Authors: Teixeira Pedro G.R. , Inaba Kenji , Dubose Joseph , Salim Ali , Brown Carlos , Rhee Peter , Browder Timothy , Demetriades Demetrios
Published: June 2020

Enterocutaneous fistula (ECF) is an uncommon and poorly studied postoperative complication. The objective of this study was to analyze the incidence and resource utilization of patients who developed an ECF after trauma laparotomy. All patients with an ECF occurring after trauma laparotomy at a Level I trauma center were identified through a review of both the Trauma Registry and the Morbidity and Mortality reports for a 9-year period ending in December 2006. Each ECF case was matched with a control (non-ECF) that did not develop this complication after laparotomy. The matching criteria were: age, gender, mechanism of injury, Injury Severity Score, Abbreviated Injury Score, and damage control laparotomy requiring an open abdomen. Outcomes analyzed were intensive care unit (ICU) and hospital length of stay, mortality, and total hospital charges. During the 9-year period, of 2373 acute trauma laparotomies performed, 36 (1.5%) patients developed an enterocutaneous fistula, and were matched to 36 controls. Patients with an ECF were 31 ± 12 years of age, were 97 per cent male, had a mean Injury Severity Score of 21 ± 10, and 75 per cent were penetrating. Eighty-nine per cent of the ECF patients had a hollow viscus injury. The most common was colon (69%), followed by small bowel (53%), duodenum (36%), and stomach (19%). Fifty-six per cent of the ECF patients had multiple hollow viscus injuries. The development of an ECF was associated with significantly increased ICU length of stay (28.5 ± 30.5 vs 7.6 ± 9.3 days, P = 0.004), hospital length of stay (82.1 ± 100.8 vs 16.2 ± 17.3 days, P < 0.001), and hospital charges ($539,309 vs $126,996, P < 0.001). In conclusion, the development of an enterocutaneous fistula after laparotomy for trauma resulted in a significant impact on resource utilization including longer ICU and hospital length of stay and higher hospital charges. Further investigation into the prevention and treatment of this costly complication is warranted.
Laparoscopic versus Open Total Mesorectal Excision: A Nonrandomized Comparative Prospective Trial in a Tertiary Center in Mexico City
Authors: GonzÁLez QuintÍN H. , RodrÍGuez-Zentner Homero A. , Moreno-Berber J. Manuel , Vergara-FernÁNdez Omar , De LeÓN HÉCtor Tapia-Cid , Jonguitud Luis A. , Ramos Roberto , Moreno-LÓPez J. AndrÉS
Published: June 2020

Because definitive long-term results are not yet available, the oncologic safety of laparoscopic surgery in rectal cancer remains controversial. Laparoscopic total mesorectal excision (LTME) for rectal cancer has been proposed to have several short-term advantages in comparison with open total mesorectal excision (OTME). However, few prospective randomized studies have been performed. The main purpose of our study was to evaluate whether relevant differences in safety and efficacy exist after elective LTME for the treatment of rectal cancer compared with OTME in a tertiary referral medical center. This comparative nonrandomized prospective study analyzes data in 56 patients with middle and lower rectal cancer treated with low anterior resection or abdominoperineal resection from November 2005 to November 2007. Follow-up was determined through office charts or direct patient contact. Statistical analysis was performed using χ2 test and Student's t test. Twenty-eight patients underwent LTME and 28 patients were in the OTME group. No conversion was required in the LTME group. Mean operating time was shorter in the laparoscopic group (LTME) (181.3 vs 206.1 min, P < 0.002). Less intraoperative blood loss and fewer postoperative complications were seen in the LTME group. Return of bowel motility was observed earlier after laparoscopic surgery. There was no 30-day mortality and the overall morbidity was 17 per cent in the LTME group versus 32 per cent in the OTME group. The mean number of harvested lymph nodes was greater in the laparoscopic group than in the OTME group (12.1 ± 2 vs 9.3 ± 3). Mean follow-up time was 12 months (range 9-24 months). No local recurrence was found. LTME is a feasible procedure with acceptable postoperative morbidity and low mortality, however it is technically demanding. This series confirms its safety, although oncologic results are at present comparable with the OTME published series with the limitation of a short follow-up period. Further randomized studies are necessary to evaluate long-term clinical outcome.
The Number of Gunshot Wounds Does Not Predict Injury Severity and Mortality
Authors: Cripps Michael W. , Ereso Alexander Q. , Sadjadi Javid , Harken Alden H. , Victorino Gregory P.
Published: June 2020

It is presumed that as the number of gunshot wounds (GSWs) increases, so do the Injury Severity Score (ISS) and mortality risk. We hypothesized that the number of bullet wounds relates to ISS and death; however, a single GSW to the head is ominous. We reviewed the charts of all GSW patients admitted to a trauma center from 2004 to 2006 (n = 531). We analyzed patient demographics, ISS, and mortality. There was no correlation with the number of GSWs with either ISS or mortality. There was only a 0.3 per cent increased risk of death for each additional GSW ( r2 = 0.12). Patients with a single GSW versus multiple GSWs had no difference in mortality (9.1 vs 8.4%, P = 0.8). A single GSW to the head carried a 50 per cent mortality risk. For those who sustained both head and body GSWs, each additional GSW did not increase mortality ( r2 = 0.007). Our study shows that the number of GSWs has no affect on mortality or ISS. Internal triage and management of gunshot victims should not be affected by the categorization of patients as having a single versus multiple GSWs.
Heparin-Coated Stents Do Not Protect Cancer Patients from Cardiac Complications after Noncardiac Surgery
Authors: Sherman Karen L. , Obi Shawn H. , Aranha Gerard V. , Yao Katherine A. , Shoup Margo C.
Published: June 2020

Previous studies regarding preoperative coronary stents and antithrombotic agents have excluded patients with cancer as a result of hypercoagulability. The objective of this study is to determine whether preoperative heparin-coated coronary stents are as safe in patients with cancer undergoing surgery as patients without cancer. Between February 2003 and February 2005, 29 patients had heparin-coated coronary stents placed before noncardiac surgery. The incidence of postoperative myocardial infarction (MI) and/or death was compared in patients with and without cancer, and outcomes were further evaluated based on preoperative antithrombotic status. Postoperative MI occurred in three of 13 (23%) patients with cancer compared with zero of 16 non-cancer patients. Patients with cancer were 9.6 times more likely to have a postoperative MI resulting in death compared with noncancer patients. There was a positive correlation between patients having cancer and having a postoperative MI ( r = 0.38, P = 0.044) and between patients with cancer being on antithrombotic medications during surgery and having a postoperative MI ( r = 0.567, P = 0.044). After stent placement, patients with cancer undergoing surgery experienced a higher incidence of postoperative MI resulting in death compared with noncancer patients despite continued antithrombotic use. In these patients, alternatives to stenting should be considered to avoid perioperative cardiac complications.
The Effect of Abdominal Binders on Postoperative Pulmonary Function
Authors: Larson Christopher M. , Ratzer Erick R. , Davis-merritt Deborah , Clark Jeffrey R.
Published: June 2020

Abdominal binders are ordered by some surgeons postoperatively for patient comfort and to prevent wound complications. There has been some question as to the compressive effect that an abdominal binder has on pulmonary function. We prospectively randomized 54 patients undergoing a midline laparotomy incision to two groups: a “binder” group and a “no binder” group. Preoperative pulmonary function tests (vital capacity and incentive spirometry) were measured. Postoperatively, pulmonary function tests, pulse oximetry, oxygen requirement, pulmonary and wound complications, pain control, time to ambulation, and hospital length of stay were examined. Vital capacity as a per cent of preoperative values on postoperative Day 1 for the binder and nonbinder groups were 64.7 and 54.6 per cent, respectively, but this was not statistically significant. Average level of pain using the visual analog pain scale on postoperative Days 1 through 3 in the binder versus nonbinder groups was 4 versus 8, 3 vs 6, and 3 versus 7, respectively. Time to ambulation was 18.6 hours in the binder group and 16.7 hours in the nonbinder group. Hospital length of stay in the binder and nonbinder groups was 3.9 days and 3.7 days, respectively. We conclude that abdominal binders in our patients with midline abdominal incisions had no significant effect on postoperative pulmonary function, but seemed to help with pain control.
Preformed Silastic Silos in the Management of Necrotizing Enterocolitis
Authors: Moore Amy B. , Nakayama Don K.
Published: June 2020

Necrotizing enterocolitis (NEC) is sometimes complicated by abdominal compartment syndrome, a clinical syndrome characterized by multiple organ dysfunction that arises as a consequence of increased intra-abdominal pressure. The evolving clinical picture of NEC sometimes requires “second-look” operations done after initial abdominal exploration to more accurately gauge the optimal extent of surgery. Placing intestines in a preformed, spring-loaded, transparent Silastic silo, traditionally used in the staged treatment of gastroschisis, addresses both situations: decompression of the abdomen and allowing periodic inspection of the intestines. Standard silos were used in three infants with advanced (Bell Class 3) NEC without perforation before definitive surgery. Clinical indices and laboratory values were recorded during the patients’ hospital courses. All three infants had extensive areas of intestinal ischemia and necrosis. FiO2, acidosis, and urinary output remained stable or improved in two patients. Silo placement corrected abdominal compartment syndrome in the third patient. Intestinal resection was required in all infants, each achieving surgical resolution of NEC. Two patients ultimately died from respiratory and neurologic complications. Application of a silo addresses abdominal compartment syndrome as a complication of NEC and allows continual inspection of the intestines. Physiological indices may improve the patient's overall clinical status.
The Modified Fontan Procedure and Prolonged Pleural Effusions
Authors: Mascio Christopher E. , Wayment Matthew , Colaizy Tarah T. , Mahoney Larry T. , Burkhart Harold M.
Published: June 2020

The modified Fontan procedure may be complicated by prolonged pleural drainage. Predisposing factors are not fully understood. This study examines perioperative variables associated with prolonged effusions. We examined the Fontan procedure in 41 patients. Mean age was 45 months (range, 9 to 113 months). Mean weight was 14.7 kg (range, 6.9 to 30.4 kg). Diagnoses included tricuspid atresia in 29 per cent, pulmonary atresia in 12 per cent, and double-outlet right ventricle in 12 per cent. Fontan revisions were excluded. The extracardiac Fontan was performed in 22 patients (54%) and the lateral tunnel (LT) in 18 (44%). Fenestration was performed in 56 per cent. Ten patients (24%) had prolonged pleural effusions. Mean chest tube output (24.2 vs 14.1 mL/kg/d, P < 0.01), days with chest tubes (10.2 vs 5.8 days, P < 0.01), and length of stay (20.8 vs 8.13 days, P < 0.01) were significantly greater in those with effusions. Preoperative mean pulmonary artery pressure was higher in patients with prolonged effusions (12.7 vs 9.90 mmHg, P = 0.001). No other factors were identified as risk factors. Prolonged pleural effusions (greater than 14 days) are common after the modified Fontan procedure. A higher preoperative mean pulmonary artery pressure may be predictive of these effusions. Fenestration, type of Fontan reconstruction, and size of extracardiac conduit did not predispose to postoperative effusions.
Acute Mesenteric Ischemia: The Importance of Early Surgical Consultation
Authors: Eltarawy Islam G. , Etman Yasser M. , Zenati Mazen , Simmons Richard L. , Rosengart Matthew R.
Published: June 2020

Acute mesenteric ischemia continues to be associated with high mortality. We hypothesized that delays in surgical consultation and operation are independently associated with increased mortality and sought to identify modifiable characteristics associated with delayed management. We conducted a retrospective cohort study of 72 patients diagnosed with acute mesenteric ischemia. Twenty-six (36%) patients died, of which 14 (54%) had care withdrawn. Delay in operation (>6 hours after surgical consultation) was associated with increased mortality (adjusted OR 3.7; 90% CI, 1.1-12). For patients for whom care was not withdrawn, delay in surgical consultation (>24 hours after disease onset) was associated with increased mortality (adjusted OR, 9.4; 90% CI, 1.3-65), as was delay in operation (adjusted OR, 4.9; 90% CI, 1.1-22). For those managed medically, early surgical consultation was associated with improved mortality (Odds Ratio [OR], 0; 90% Confidence Interval [CI], 0-0.34). Patients with delayed surgical consultation were more likely to have abdominal distension, elevated lactate concentration, acute renal failure, vasopressor administration, and a lack of abdominal pain. The acquisition of CT imaging trended toward an association with delayed surgical consultation ( P = 0.06). We conclude that early surgical consultation is associated with improved outcome even for patients managed without operative intervention, and that CT imaging may delay appropriate care.
Gunshot Wounds to the Head in Civilian Practice
Authors: Glapa Miriam , Zorio Maurizio , Snyckers Frank D. , Bowley Douglas M. , Yilmaz Tugba Han , Doll Dietrich , Degiannis Elias
Published: June 2020

Gunshot wounds to the head are associated with poor outcome. We reviewed data to identify prognostic factors. We performed a retrospective study of all patients admitted to a Level 1 trauma center with isolated gunshot injury to the head during 6% years. Data collected included demographics, mechanism of injury, prehospital and resuscitation room data, and initial CT scan characteristics. The primary outcome measure was the Glasgow Outcome Scale. Seventy-two patients with isolated gunshot wounds to the head were admitted. Overall mortality was 58 per cent. The mortality for patients with an initial Glasgow Coma Scale score of ≤8 was 81 per cent versus 14 per cent for those with initial Glasgow Coma Scale score > 8 ( P ≤ 0.0001). Fifty per cent had pupillary abnormalities on arrival at the Emergency Department. Mortality in this group was 78 per cent versus 53 per cent in those with normal pupillary reflexes ( P = 0.06). Elevated plasma lactate was associated with nonsurvival. Thirteen per cent of survivors were assessed as able to live independently after their injury. Civilian gunshot injury to the head is related to high mortality. Indicators of outcome are the admission Glasgow Coma Scale score, pupillary abnormality, metabolic acidosis, and CT pattern of severe injury. The majority of deaths occur at an early stage. Among survivors the functional outcome can be acceptable.
Partial Cholecystectomy in the Setting of Severe Inflammation is an Acceptable Consideration with Few Long-Term Sequelae
Authors: Sharp Collin F. , Garza R. Zachary , Mangram Alicia J. , Dunn Ernest L.
Published: June 2020

Open cholecystectomy is infrequently performed. For the general surgeon, open cholecystectomy is typically performed when a great degree of inflammation precludes safe laparoscopic removal. The degree of inflammation can also lead to an unacceptable risk of common bile duct injury during the dissection of the triangle of Calot. In this situation, the extent of dissection and amount of resection is not well established. We undertook a retrospective review and follow-up telephone questionnaire of all partial cholecystectomies performed. Partial cholecystectomy was performed in 26 cases with open, laparoscopic converted to open, and laparoscopic techniques. Postoperative complications occurred in seven (27%) patients with three (12%) experiencing more than one complication. There was a bile leak in three (12%), subhepatic abscess in three (12%), wound infection in two (8%), and retained common duct stone in one (4%). There were no common bile duct injuries and no deaths. Telephone interviews were conducted with 19 (73%) patients. Average length of follow up was 314 days. At the time of last contact, no ongoing complaints attributable to biliary pain were present. Our data suggest that partial cholecystectomy in the setting of severe inflammation is a reasonable operation with few long-term sequelae, good clinical results, and satisfactory symptom relief.
Advances in the Management of Blunt Thoracic Aortic Injury: Parmley to the Present
Authors: Fabian Timothy C.
Published: June 2020

This article traces the evolution in management of blunt aortic injury (BAI) over the past 50 years from the time of the seminal description from Parmley in 1958. There have been major advances in both diagnostics and treatment paradigms with very rapid technologic advances occurring over the past decade. For many years, conventional aortography was the principle diagnostic tool, but it has been replaced by the progression of CT. The widespread adoption of antihypertensive therapy has sharply reduced the incidence of aortic rupture before planned reconstruction. Many patients with major associated injuries have definitive treatment of BAI managed in a delayed fashion with the use of hypertensives, which appears to improve outcomes. In the past 5 years, definitive treatment has changed with the majority of injuries being treated today with endoluminal stent grafts as opposed to open thoracotomy and traditional repair techniques. Paraplegia rates have diminished from 8 to 10 per cent down to 1 to 2 per cent in association with these therapeutic advances.
Patients with Cushing's Syndrome are Care-Intensive Even in the Era of Laparoscopic Adrenalectomy
Authors: Kissane Nicole A. , Cendan Juan C.
Published: June 2020

We report outcomes from laparoscopic adrenalectomy (LA) comparing patients with Cushing's syndrome with those with other adrenal pathology with respect to length of stay (LOS), overall complications, and financial implications. We conducted a retrospective review of 80 continuous patients (103 glands) undergoing LA. The clinical diagnoses were: hypercortisolism (Cushing’ syndrome; n = 33), hyperaldosteronism (Conn's syndrome; n = 20), phaeochromocytoma (n = 16), and neoplasm (others; n = 11). Advanced care in the intermediate or intensive care unit was necessary in 27 patients, most frequently in our Cushing's population (16 of 33 [48%]). Six patients sustained major complications, including death in two patients; seven patients sustained minor complications. LOS was longer for patients with Cushing's syndrome (mean, 5.5 vs 3.3 days; P = 0.024). Financially, patients with Cushing's syndrome had statistically higher total hospital ( P = 0.009), advanced care ( P = 0.002), and anesthetic costs ( P = 0.005). LA in patients with Cushing's syndrome is associated with longer hospitalizations, more frequent major complications, and higher advanced care requirements, especially for patients undergoing bilateral adrenalectomy Minor complications were infrequent and median LOS was brief regardless of diagnosis. Patients with Cushing's syndrome had higher costs for overall hospital charges, advanced care, and anesthesia.
Article Commentary: Advancements in Cardiopulmonary Resuscitation: Increasing Circulation and Improving Survival
Authors: Ramsay Philip T. , Maxwell Robert A.
Published: June 2020

Clinicians, as well as lay people, have realized the importance of resuscitative maneuvers throughout recorded history. Cardiopulmonary resuscitation has evolved from a relatively primitive technique to one now dictated by data from evidence based medicine. Recent advancements include changes in life support guidelines, the development of an impedance threshold device, and the initiation of therapeutic hypothermia. We can only expect continued advancements in cardiopulmonary resuscitation through new technology with resultant improved outcomes.
Does Shave Biopsy Accurately Predict the Final Breslow Depth of Primary Cutaneous Melanoma?
Authors: Moore Phillip , Hundley Jon , Hundley Jennifer , Levine Edward A. , Williford Phillip , Sangueza Omar , Mccoy Thomas , Shen Perry
Published: June 2020

Shave biopsy (SB) is used for the diagnosis of suspicious skin lesions, including melanoma. Its accuracy for melanoma has not been confirmed. We examined our experience with SB to determine its ability to predict true Breslow depth (BD). We performed a retrospective review of the tumor registry for all patients diagnosed with melanoma by SB from 1995 to 2004. Site and depth of lesion, tumor stage, correlation of BD between SB and wide local excision (WLE), and changes in surgical management due to discordance were examined. Melanoma-in-situ was defined as a depth of 0 for this analysis. One hundred thirty-nine patients were diagnosed with melanoma by SB. Pathology after WLE were as follows: 54 (39%) patients had no residual disease, 67 (48%) had a BD equal to or less than the SB, and 18 (13%) had a thicker BD compared with the SB. For these 18 patients, the median BD by SB and WLE was 1.1 mm (range 0-6.5) and 3.5 mm (range 0.5-20.5), respectively ( P = 0.0017). Upstaging of final BD from SB to WLE was significantly associated with increasing tumor depth and higher stage of melanoma ( P < 0.0001). Only seven of the 139 patients (5%) required further surgery because of the increased depth of the WLE. SB underestimated the final BD of melanoma in 13 per cent of patients, but changed the management of few patients. SB is a valuable tool for practitioners in the diagnosis of melanoma. Nevertheless, patients diagnosed with melanoma by SB should be counseled about the rare need for additional surgery.
Infrahepatic Vena Cavocavostomy, a Modification of the Piggyback Technique for Liver Transplantation
Authors: Khanmoradi Kamran , Defaria Werviston , Nishida Seigo , Levi David , Kato Tomoaki , Moon Jang , Selvaggi Gennaro , Tzakis Andreas
Published: June 2020

We describe our experience with a modification of the piggyback (PB) technique for orthotopic liver transplantation in which the donor infrahepatic vena cava is used as the venous outflow tract. From May 1997 to January 2006, a total of 109 cases using this technique were performed in 101 patients. Collected data included recipient demographics and diagnosis, warm ischemia time, use of venovenous bypass or temporary portacaval shunt and complications related to the venous outflow and graft, and patient survival. Data were compared with the patients undergoing standard PB technique during the same period. The reasons for using the technique were grouped according to whether there was a problem with the recipient hepatic veins or a concern about the length or diameter of the donor suprahepatic vena cava. These included the presence of a trans-jugular intrahepatic portosystemic shunt (eight cases), retransplantation (22 cases), thin-walled, friable hepatic veins (32 cases), Budd-Chiari syndrome (two cases), domino liver procurement (six cases), reduced or split liver grafts (five cases), and graft inferior vena cava to recipient hepatic veins size discrepancy (34 cases). There was no graft loss. The warm ischemia time was 39.65 minutes compared with 37 minutes in the standard PB group. The long-term graft and patient survival rates were similar in the two groups. Infrahepatic vena cavocavostomy is a useful variation of the standard PB technique.
Multimodality Treatment for Esophageal Malignancy: The Roles of Surgery and Neoadjuvant Therapy
Authors: Malin Edward , Kiernan Paul D. , Sheridan Michael J. , Khandhar Sandeep J. , Fraser Cheryl , Hetrick Vivian
Published: June 2020

The best curative treatment for esophageal malignancy remains controversial. In 2003, we presented our institution's experience with 124 patients treated from 1990 to 2001. Here we update that experience with an additional 6 years’ data. A total of 221 patients underwent surgical resection from 1990 to 2007; 128 had up-front surgery, 88 underwent surgery after neoadjuvant radiation and chemotherapy (NARCS), and five underwent surgery after neoadjuvant, single-agent therapy Principle outcomes of interest were 30-day and in-hospital mortality as well 3- and 5-year survival rates. Overall 3- and 5-year survival rates were 38 and 33 per cent. NARCS achieved complete pathologic result in 32 per cent of patients with corresponding 3- and 5-year survival rates of 58 and 53 per cent. The 3- and 5-year survival rates for all patients undergoing NARCS were 36 and 31 per cent versus 24 and 18 per cent for patients with up-front surgery for anything over Stage I disease ( P = 0.01). The 3- and 5-year survival rates for patients with up-front resection of Stage I disease were 78 and 70 per cent. Overall, 30-day and in-hospital mortalities were 1.8 and 2.3 per cent. Since January 1, 2000, hospital mortality has been less than 0.8 per cent. We prefer NARCS for malignancy of the esophagus, except in those patients with high-grade dysplasia (carcinoma in situ), suspected Stage I disease, poor performance status, or urgent/emergent circumstances.
Early Results of Midline Hernia Repair Using a Minimally Invasive Component Separation Technique
Authors: Bachman Sharon L. , Ramaswamy Archana , Ramshaw Bruce J.
Published: June 2020

A minimally invasive component separation may lead to a dynamic abdominal wall after hernia repair, with reduced complications. We present early results of our patients undergoing this technique. Five patients were selected for open midline repairs; three with chronic infections, one with a prior midline skin graft, and one who desired a primary, tension-free repair. These three males and two females had a mean age of 50.8 ± 21.1 years and body mass index of 30.9 ± 6.2. The mean number of previous abdominal operations was 7 ± 3.4 and previous attempted hernia repairs were 4 ± 2.7. All patients had a midline laparotomy with lysis of adhesions. An endoscopic component separation was then performed bilaterally. Drains were left in the dissection bed. All patients had the midline closed; four received biologic mesh underlays. Mean operative time was 227 minutes ± 49. Mean length of stay (LOS) was 9.2 days ± 3.6. Early median follow-up was 6 months (range 0.25–9). Two patients required postop transfusions, and two patients had mild complications of the midline wound (hematoma, infection). To date, one recurrence was diagnosed by CT scan. Early evaluation of adopting the minimally invasive (MIS) component separation demonstrates minimal complications and good initial outcomes.
Do Melanoma Patients from Southern Climates have a Worse Outcome than those from Northern Climates?
Authors: Woodall Charles E. , Martin Robert C. G. , Stromberg Arnold J. , Ginter Brooke , Burton Alison , Ross Merrick I. , Edwards Michael J. , Mcmasters Kelly M. , Scoggins Charles R.
Published: June 2020

Sun exposure is known to cause melanoma; what is not known is whether patients from the Southern United States have a different profile of clinicopathologic factors and outcomes than those from the Northern United States. Data from a prospective, randomized trial on surgery for cutaneous melanoma were analyzed. All patients underwent wide excision and sentinel lymph node biopsy. Patients were categorized into two groups: Northern or Southern according to their state of residence. Clinicopathologic factors and outcomes were compared between groups. A total of 2025 patients were included in the analysis; 1214 (60%) were from Southern states. The median follow-up was 52 months. Despite significant differences in clinicopathologic features between groups on both univariate and multivariate analysis, two important factors, namely primary tumor thickness and ulceration were not different, nor was the rate of lymph node metastasis. Additionally, there were no differences in disease-free survival or overall survival between the two groups. Significant differences exist between primary melanomas based on geographic regions; however there are no differences in survival. Cumulative versus episodic sun exposure may play some role in these differences.
Fecal Diversion in Perirectal Fistulizing Crohn's Disease is an Underutilized and Potentially Temporary Means of Successful Treatment
Authors: Rehg Kellee L. , Sanchez Jaime E. , Krieger Beth R. , Marcet Jorge E.
Published: June 2020

The purpose of this study was to determine the outcome of patients treated with fecal diversion for perirectal fistulizing Crohn's disease. Thirty-nine patients were identified and followed for an average of 60 months. Patients were divided into two groups based on surgical treatment: local surgical treatment only and fecal diversion in addition to local surgical therapy. Thirteen patients (33%) underwent fecal diversion due to the severity of their disease. Eleven of these patients (85%) had complete resolution of their fistulas and only two (15%) required proctectomy. In contrast, only five out of 26 patients (19%) who underwent local surgical procedures alone had complete perirectal disease resolution. Intestinal continuity was restored in six patients (46%) and three of these patients (50%) remained disease free. The remaining three patients had disease recurrence, which required additional local procedures in one patient (17%), but with eventual resolution; the other two patients (33%) necessitated rediversion. Our data suggest that fecal diversion is a viable treatment option for severe perirectal fistulizing Crohn's disease and may be associated with a higher rate of resolution than local surgical treatment alone. In addition, we demonstrate a higher rate of successful intestinal continuity restoration than is typically reported.
Effects on Health of Volunteers Deployed during a Disaster
Authors: Swygard Heidi , Stafford Renae E.
Published: June 2020

Little is known about the risks, hazards, and health outcomes for health care personnel and volunteers working in disaster relief. We sought to characterize risks and outcomes in volunteers deployed to provide relief for victims of Hurricane Katrina. We performed a longitudinal e-mail survey that assessed preventive measures taken before and during deployment, exposures to hazards while deployed, and health outcomes at 1, 3, and 6 months postdeployment. Overall response rate was 36.1 per cent and one-third of those who responded did so for all three surveys. Exposures to different types of hazards changed over time with exposures to contaminated water being common. Despite predeployment and on-site education, use of preventive measures such as vaccination, appropriate clothing, hydration, sunscreen, and insect repellant was variable. Few injuries were sustained. Insect bites were common despite the use of insect repellants. Skin lesions, diarrhea, and other gastrointestinal complaints occurred most commonly early on during or after deployment. Psychological complaints were common at 3 and 6 months. In conclusion, identification of at risk volunteer cohorts with longitudinal surveillance is critical for future disaster planning to provide training for volunteers and workers and to allow for deployment of appropriate resources pre, during, and postdeployment.
Odontogenic Ameloblast Associated Protein as a Novel Biomarker for Human Breast Cancer
Authors: Siddiqui Sabina , Bruker C. Todd , Kestler Daniel P. , Foster James S. , Gray Keith D. , Solomon Alan , Bell John L.
Published: June 2020

Odontogenic Ameloblast Associated Protein (ODAM) is a protein isolated in ameloblasts during odontogenesis. ODAM expression was identified in breast cancer, but its significance remains unknown. The purpose of this study is to determine if ODAM expression can serve as a prognostic marker and provide information regarding treatment in human breast cancer. Breast cancer patients were identified from our tumor registry from 1993 to 2003. Archived breast cancer tissue from 243 patients (stage 0 = 53, stage I = 51, stage II = 53, stage III = 47, stage IV = 39) was stained using monoclonal antibody for ODAM. Presence or absence of immunostaining was correlated with stage, histologic grade, response to chemotherapy, and survival using χ2 and logistic regression analyses. Tumor nuclear staining for ODAM increased with increasing group stage ( P < 0.001). Staining for ODAM did not correlate with histologic grade or chemotherapy ( P = 0.558, P = 0.093). Improved outcomes within each stage were noted with ODAM staining, statistically significant for stages 0, I, and II ( P < 0.001, P = 0.003, P = 0.003) and underpowered for stages III and IV ( P = 0.724, P = 0.059). Survival benefit associated with tumor nuclear staining increased with advancing stage ( P < 0.001). These results show that ODAM predicts survival in breast cancer. Research is ongoing to determine ODAM's clinical utility and role in carcinogenesis.
Unplanned Intubation after Surgery: Risk Factors, Prognosis, and Medical Emergency Team Effects
Authors: Snyder Christopher W. , Patel Roshan D. , Roberson Emily P. , Hawn Mary T.
Published: June 2020

Unplanned intubation after surgery is a marker for severe adverse events. We investigated the incidence, risk factors, and prognosis of unplanned intubation after general and vascular surgery and sought to determine whether the deployment of a hospital-wide medical emergency team (MET) had a preventive effect. We included all patients undergoing general and vascular surgical procedures between April 1, 2006, and June 30, 2008, from our American College of Surgeons National Surgical Quality Improvement Program data. Risk factors and incidence rates of unplanned intubation were compared before (preMET) and after (postMET) June 7, 2007. Chart review identified case details and fatality rates. There were 2426 patients included (1815 preMET, 611 postMET). The overall incidence of unplanned intubation was 2.6 per cent; significant risk factors included chronic obstructive pulmonary disease, dependent functional status, and emergent operation. Most (84%) unplanned intubations occurred in a critical care setting and the most common underlying reason was sepsis (40%). The overall case fatality rate was 43 per cent but varied significantly depending on the underlying reason for unplanned intubation. Incidence rates of unplanned intubation did not change significantly after MET deployment, suggesting that other strategies are needed to prevent this rare but highly morbid and mortal event.
The Impact of the Ratio of Positive to Total Lymph Nodes Examined and Outcome in Colorectal Cancer
Authors: Ng Melody , Roy-Chowdhury Sharmila , Lum Sharon S. , Morgan John W. , Wong Jan H.
Published: June 2020

We sought to examine the significance of the number of nodes examined in node-positive colorectal cancer. Between January 1, 1994, and December 31, 2003, 7192 patients with colorectal cancer underwent potentially curative resection in Region 5 of the California Cancer Registry. Of these patients, 2636 patients were node-positive: 65.1 per cent were N1 and 34.9 per cent were N2. The median follow up was 39.5 months. The mean number of nodes examined was 10.4 (range, 1-89) for NO, 11.0 (range, 1-72) for N1, and 14.6 (range, 4-79) for N2 ( P < 0.0001). N1 and N2 patients were stratified according to the percentage of positive nodes into quintiles (0.19 or less, 0.20 to 0.39, 0.40 to 0.59, 0.60 to 0.79, and 0.80 to 1.0). In both N1 and N2 disease, a lower percentage of lymph nodes involved with metastatic disease was associated with improved survival ( P < 0.0001). The increasing ratio of positive to total nodes was the result of a decrease in the total number of nodes examined in N1 disease and a steeper decline in total nodes examined in relation to the increase in the number of positive nodes in N2 disease. The ratio of positive to total nodes has prognostic significance in node-positive colorectal cancer.
Management of Vascular Graft Infections with Soft Tissue Flap Coverage: Improving Limb Salvage Rates–A Veterans Affairs Experience
Authors: Herrera Fernando A. , Kohanzadeh Som , Nasseri Yosef , Kansal Nikhil , Owens Eric L. , Bodor Richard
Published: June 2020

Graft infections are one of the most challenging issues in surgery with an incidence of 0.7 to 7 per cent, with femoral site infections being the most common (13% incidence). The gold standard treatment has been graft removal, wide debridement, and extra-anatomical bypass. Routine excision of infected peripheral arterial grafts and vascular reconstruction with extraanatomic conduits are associated with mortality rates ranging from 10 to 30 per cent and amputation rates of up to 70 per cent. As a result of the high morbidity and mortality associated with this approach, selective graft preservation techniques have been developed. Newer treatment plans discuss preservation of the graft with debridement and coverage of the infected region. Better wound care, nutrition optimization, and robust flap coverage have led to significantly improved graft salvage, lower amputation rates, and improved outcomes. The objective of this study was to evaluate the Veterans Affairs (VA) experience with flap coverage for femoral vascular graft infections. A retrospective review was conducted of all VA data from 1997 to 2008 with inclusion criteria of patients with deep groin wound infections requiring flap coverage after femoral bypass surgery. Eleven such patients were identified with a mean age of 73 years and with multiple comorbidities (hypertension, malnutrition, diabetes mellitus, chronic obstructive pulmonary disease, coronary artery disease, chronic renal insufficiency). Patients presented with wound drainage, exposed graft, hematoma, perigraft fluid collection, and pseudoaneurysm. Treatment protocol included: 1) aggressive debridement of the wound bed; 2) early soft tissue (flap) coverage; 3) wound vacuum assisted closure device or frequent dressing changes; and 4) skin graft once the bed was prepared. Eighty-two per cent of wounds had positive cultures with equal numbers of patients with Staphylococcus epidermidis, Pseudomonas, Escherichia coli (22%), and higher methicillin-resistant Staphylococcus aureus (33%), whereas in the literature Staphylococcus is the most common (greater than 50%). Average hospital length of stay was 94 days with average follow up at 10 months. Fifty-five per cent graft salvage (one Dacron [50%], two polytetrafluoroethylene [33%], two saphenous vein graft [100%], one cryovein [100%]) was achieved with 91 per cent limb salvage. Complications included graft blowout (two) requiring partial flap loss (one), retroperitoneal hematoma (one), limb loss (one), sepsis (one), and death (one). Infected vascular grafts remain a challenging problem requiring multidisciplinary care. Careful debridement and aggressive wound care followed by selective flap coverage appears to decrease morbidity and increase graft and limb salvage.
Botulinum Toxin A with Fissurectomy is a Viable Alternative to Lateral Internal Sphincterotomy for Chronic Anal Fissure
Authors: Aivaz Ohara , Rayhanabad Jessica , Nguyen Vincent , Haigh Philip I. , Abbas Maher
Published: June 2020

Lateral internal sphincterotomy (LIS) is the gold standard surgical treatment for anal fissure. However, it carries potential complications, including fecal incontinence. The goal of this retrospective study was to compare the outcome of botulinum toxin A injection coupled with fissurectomy ([BTX + FIS) versus LIS. There were 59 patients who underwent BTX + FIS or LIS over a 5-year period. LIS was performed in the standard fashion without fissurectomy. BTX + FIS entailed internal sphincter injection with 80 units of botulinum toxin A coupled with fissurectomy. Forty patients underwent LIS and 19 had BTX + FIS. The choice of operation was based on the patient's preference. Primary healing rate was 90 and 74 per cent in the LIS and BTX + FIS groups, respectively ( P = 0.13). The complication rate was 10 per cent in the LIS vs 0 per cent in the BTX + FIS groups ( P = 0.29). Complications of LIS included anal sepsis in one patient and flatal and/or fecal incontinence in three patients. During a mean follow up of 19 months; recurrence rate was 0 and 5 per cent in the LIS and BTX+FIS groups, respectively ( P = 0.32). The results of this study demonstrate that BTX + FIS is a viable alternative to LIS for patients with chronic anal fissure and should be considered as an alternative first-line surgical therapy.
Early Experience with Laparoscopic Sleeve Gastrectomy as a Single-Stage Bariatric Procedure
Authors: Lewis Catherine E. , Dhanasopon Andrew , Dutson Erik P. , Mehran Amir
Published: June 2020

Laparoscopic sleeve gastrectomy (LSG) as a single-stage restrictive bariatric procedure is becoming increasingly popular, especially in patients who are high risk and/or superobese. Between November 21, 2006, and September 30, 2008, 42 patients underwent LSG at our institution. Average age was 47 ± 11 years, average body mass index was 54 ± 10 kg/m2, and 62 per cent were female. Preoperative indications for LSG included contraindication to laparoscopic Roux-en-Y gastric bypass (n = 11), severe coronary artery disease and/or congestive heart failure (n = 3), significant liver disease (n = 3), and patient preference (n = 4). Intraoperative indications for LSG included a foreshortened mesentery with inability to create a gastrojejunostomy (n = 13), extensive adhesions (n = 5), and intraoperative findings concerning for cirrhosis (n = 3). Twelve complications occurred in six patients: laparoscopic to open conversion (n = 1), reoperation (n = 3), nosocomial pneumonia (n = 1), wound infection (n = 1), bleeding (n = 1), pulmonary embolus (n = 1), readmission (n = 3), and superior splenic pole infarction. There was one death resulting from pulmonary embolism that occurred 2 weeks postoperatively. Preliminary excess body weight loss at 3, 6, 9, and 12 months was 29, 32 t, 38, and 30 per cent, respectively, and many patients had improvement or resolution of obesity-related comorbidities. Early review of our experience demonstrates that LSG may be an effective single-stage bariatric procedure. Additional follow up will be necessary to better define its long-term safety and efficacy.
Elevated Blood Alcohol Level May be Protective of Trauma Patient Mortality
Authors: Yaghoubian Arezou , Kaji Amy , Putnam Brant , De Virgilio Nicholas , De Virgilio Christian
Published: June 2020

To determine whether a positive blood alcohol level (BAL) affects morbidity and mortality at a Level I trauma center, a retrospective review of trauma patients 18 years of age and older was performed. There were 7985 trauma patients and 8 per cent (645) had a positive BAL. BAL(+) patients had lower Injury Severity Score (ISS) (8 vs 11, P < 0.01), lower rate of penetrating injury (9 vs 25%, P < 0.01), and were older (38 vs 32 years, P = 0.01). Overall there were 559 deaths (7%); (1% mortality in BAL(+) patients and 7% in BAL(-) patients; P < 0.0001). There were 352 (4.4%) complications with similar rates among BAL(-) and (+) patients. On univariate analysis, a positive BAL was inversely associated with death (OR, 0.17) as was blunt trauma (OR, 0.29), whereas older age (OR 1.009) and increased ISS (OR 1.13) were associated with death. On multivariable analysis, after adjusting for age, ISS, and mechanism of injury, a positive BAL remained protective against death (OR 0.35) as did blunt trauma (OR 0.2). Age (OR 1.04) and increased ISS (OR 1.19) were associated with mortality. In conclusion, a positive BAL was associated with a decreased mortality risk in trauma patients, which persisted after adjusting for multiple confounding variables.