bluuebunny/crossref_metadata_2025 huggingface dataset:
Axillary Lymph Node Status of T1 Primary Breast Cancer in a Diverse Population
Authors: Madan Atul K. , Macareo Louis , Winfrey Keith , Beech Derrick J.
Published: November 2022

The utility of level I and II axillary lymph node dissection in women with primary tumors less than 1 cm in diameter has recently received extensive evaluation. Numerous patients undergo axillary lymph node dissection ultimately to discover no pathological involvement. This study investigates the lymph node status in T1 primary breast adenocarcinoma in our diverse patient population. A retrospective evaluation of patients treated at the Medical Center of Louisiana at New Orleans and the Tulane University Medical Center with breast adenocarcinoma less than or equal to 2 cm was performed. Demographic data and pathological reports were reviewed to obtain breast lesion size and lymph node status. One hundred sixteen patients were found to have T1 lesions. Ethnic distribution was African American 66 per cent; Caucasians 30 per cent; Hispanic 2 per cent; and Asian 3 per cent. Whereas no patients with T1a lesions had positive lymph nodes, 11 per cent of patients with T1b lesions and 36 per cent of patients with T1c lesions had positive lymph nodes. However, in our patient population no patients with tumors less than 1.0 cm. in diameter had positive lymph nodes. Although this may be due to our relatively small sample size axillary lymph node dissection may be unnecessary in this select patient population. For patients with lesions 1.0 cm and greater an axillary lymph node dissection seems to add necessary information for correct treatment in a small percentage of patients. The use of lymphatic mapping with sentinel axillary lymph node biopsy may reduce the number of unnecessary axillary dissections in early breast cancer.
Game Theory in the Operating Room Environment
Authors: Marco Alan P.
Published: November 2022

To optimize the functioning of an operating room the interactions of the staff (physicians and nurses) and other stakeholders (administrators) must be understood. Game theory provides a representation of the interactions that typically take place in the operating room environment. By understanding the types of games/interactions that occur the participants can better predict outcome and adapt their own behavior to optimize that outcome. Types of games seen in the operating room include fixed-sum, zero-sum, and non-zero-sum games. The Prisoner's Dilemma game and some of its variations are used to illustrate common interactions in the operating room. Examples of strategies for typical scenarios are discussed as well as ways to improve the outcome of the games. A better understanding of human behavior can improve the functioning of complex systems such as that found in the operating room.
Acute Cholecystitis in the Immediate Postoperative Period following Esophagogastrectomy
Authors: Paull Douglas E.
Published: November 2022

Postoperative acute cholecystitis (PAC) occurs after 0.06 per cent of all operations. However, PAC may occur in up to 3.1 per cent of patients after gastrectomy. This increased incidence of PAC is due to bile stasis and gall bladder ischemia promoted by vagotomy and gastrohepatic ligament dissection during gastrectomy. Despite similar factors during esophagogastrectomy PAC is rarely reported in large American series of patients undergoing esophagogastrectomy. We report two cases of PAC occurring after esophagogastrectomy.
Prospective Comparison between Laparoscopic Preperitoneal Herniorrhaphy and Open Mesh Herniorrhaphy
Authors: Smith Jeffrey R. , Demers Marc L. , Pollack Robert , Gregory Susan
Published: November 2022

Controversy persists regarding the most effective inguinal hernia repair. The purpose of this study is to compare the complications, charges, patient satisfaction, and recovery time between laparoscopic (LH) and open mesh herniorrhaphy (OH). A nonrandomized prospective analysis of 233 consecutive inguinal hernia repairs was performed over a 12-month period by 27 surgeons. The type of repair was determined by surgeon preference. Cost analysis was performed using anesthesia records and hospital cost. Patient satisfaction and recovery time were evaluated by third-party interview. A total of 113 OHs and 120 LHs were performed; 11 OHs and 42 LHs were bilateral. Patient demographics were equivalent for the two groups. No statistical difference was noted when comparing anesthesia/operating room time between the two groups. The LHs accrued an additional charge of $2254 per case. Complication rates were 4.4 per cent for the OHs and 8.3 per cent for the LHs. All complications were considered minor. No infectious complications or recurrences were noted in either group. Satisfaction rates and pain indices were nearly identical for both OHs and LHs. The LHs had a shorter recovery time by 5.5 days. We conclude that LH is associated with a higher complication rate and cost than OH. Pain indices are similar, but LH has a shorter recovery time.
A Critical Appraisal of Treatment for T3N0 Colon Cancer
Authors: Yo In S. , Opelka Frank G. , Bolton John S. , Fuhrman George M.
Published: November 2022

The purpose of this study was to evaluate the impact of adjuvant chemotherapy on survival after surgery for T3N0 colon cancer. All patients with node-negative (N0) colon cancer with tumor invasion beyond the muscularis propria (T3) treated with colectomy between 1982 and 1995 at a single institution were included. Patients were divided into two groups depending on postcolectomy treatment with or without adjuvant chemotherapy. Groups were evaluated to determine perioperative and pathologic variables that could potentially influence outcome and surveillance data to determine disease-free and overall survival. In 253 patients with T3N0 colon cancer 226 remained under observation and 27 were treated with adjuvant chemotherapy. The groups were similar ( P = not significant) when compared for tumor location, size, differentiation, number of nodes harvested, and transfusion requirements. Four of the 27 patients who received chemotherapy developed a recurrence (14.8%), whereas 22 of the 226 observation patients developed a recurrence (9.7%). Disease-free survival for the chemotherapy group at 5 years was 84 per cent and for the observation group 87 per cent. Statistical analysis (Mantel-Cox) showed no significant difference between the groups on the basis of survival ( P = 0.3743). We conclude that resection alone is a highly effective treatment for T3N0 colon cancer leaving limited opportunity for adjuvant chemotherapy to significantly impact survival. Adjuvant chemotherapy for T3N0 colon cancer patients should be limited to patients enrolled in clinical trials designed to identify subgroups of T3N0 colon cancer patients at a survival disadvantage or less toxic adjuvant chemotherapies.
Laparoscopic Repair of Inguinal Hernias with Higher Risk for Recurrence: Independent Assessment of Results from 121 Repairs
Authors: Szymanski Jan , Voitk Andrus
Published: November 2022

This study attempts to determine by independent review the results of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair for hernias with increased risk for recurrence. Indicators used for increased recurrence risk were recurrent hernias or simultaneously repaired bilateral inguinal hernias. Office and hospital records of all such patients who had undergone TAPP repair were reviewed from one surgeon's 242-patient laparoscopic inguinal hernia database from 1992 to 1998. All were called for assessment by an independent surgeon at least 4 months postoperatively (median 34 months). Those unable to come in person were interviewed by telephone. There were 121 hernias: 34 recurrent and 100 bilateral (13 overlap). Recurrence rate was 3 per cent, which was similar for repair of bilateral and recurrent hernias. All recurrences occurred within 3 months of surgery. No unknown recurrence was detected by the independent observer. Laparoscopic TAPP inguinal hernia repair, often claimed as the method of choice for bilateral and recurrent hernia repair, is indeed a safe and effective procedure with a low early recurrent rate in these higher-risk situations.
Popliteal Artery Injury Associated with Knee Dislocations
Authors: Martinez Daniel , Sweatman Ken , Thompson Errington C.
Published: November 2022

Since the Vietnam War experience we have known that there is a high association between knee dislocations and popliteal artery injuries. In an effort to improve the quality of care we asked whether every patient with a knee dislocation needs an arteriogram. This is a retrospective chart review of all injured patients who presented to Louisiana State University Health Science Center with knee dislocations between January 1, 1993 and March 31, 1998. Twenty-one patients met the study criteria. There were no deaths in this series. Twelve patients presented with normal palpable pulses. Nine of these 12 patients underwent an arteriogram. There was only one abnormal arteriogram (intimal defect) in this group. None of the patients who presented with normal pulses were operated on. There were no in-hospital complications from this nonoperative management. In the group of patients with either diminished pulses or no pulses arteriograms were performed on all patients. Fifty-five per cent of these arteriograms were abnormal, and one-third of these patients (two) were taken to the operating room for repair. In the group of patients who present with knee dislocations and normal peripheral vascular examination arteriograms are not helpful.
Vaginal Metastasis of Colon Cancer
Authors: Chagpar Anees , Chandra Kanthan Selliah
Published: November 2022

True vaginal metastases from colonic cancer are exceedingly rare. This often signals an ominous prognosis. More frequently the vagina is synchronously involved by direct contiguous spread from the colonic lesion. We present a case of sigmoid carcinoma with true metastasis to the vagina that was discovered after an interval of 3 weeks when vaginal discharge became evident. To our knowledge, there are only two other papers in the English language previously documenting this phenomenon.
Hereditary Chronic Pancreatitis: Implications for Surgical Treatment and Follow-Up
Authors: Cowles Robert A. , Eckhauser Frederic E. , Knol James A.
Published: November 2022

Hereditary pancreatitis is an uncommon cause of chronic pancreatitis in Western society. It should be suspected when chronic pancreatitis presents in young adults. The diagnosis is made when chronic pancreatitis is present in several members of the same family who are determined not to have other risk factors for chronic pancreatitis. Molecular research focusing on mutations in the tripsinogen gene has uncovered the genetic defects associated with hereditary pancreatitis, and this knowledge has suggested the possible pathophysiologic mechanism of this disease. Because patients with hereditary pancreatitis develop their disease early in life they are very likely to require treatment for complications. As in patients with chronic pancreatitis of other etiologies those with hereditary pancreatitis should be treated medically for acute exacerbations. When complications occur or when the disease causes intractable pain surgery is recommended. Surgical therapy is tailored to the patient's pancreatic anatomy based on endoscopic retrograde cholangiopancreatography or CT scan. The two patients described in this report underwent successful longitudinal pancreaticojejunostomy (Puestow procedure) with good results. Finally it has been shown that patients with hereditary pancreatitis are at increased risk for developing pancreatic adenocarcinoma. Although not widely used pancreatic cancer screening programs have been suggested for surveillance of these patients.
Typical versus Atypical Presentation of Obturator Hernia
Authors: Schmidt P.H. , Bull W.J. , Jeffery K.M. , Martindale R.G.
Published: November 2022

Although it is a rare occurrence among all pelvic hernias diagnosed the obturator hernia continues to be a diagnostic challenge for surgeons today. These patients, who often have multiple concurrent medical problems, are subject to high morbidity and mortality rates resulting from late presentation and delayed surgical intervention. The vast majority of patients with obturator hernias are admitted with signs and symptoms of intestinal obstruction, namely anorexia, nausea, vomiting, constipation, and distension of 2 to 3 days’ duration. In this paper, however, we highlight a small subset of obturator hernia patients who present without obstructive symptoms and do well after elective repair. The case reports that follow serve to compare and contrast two very different presentations of this surgical problem.
Primary Venorrhaphy for Traumatic Inferior Vena Cava Injuries
Authors: Carr John Alfred , Kralovich Kurt A. , Patton Joe H. , Horst H. Mathilda
Published: November 2022

Primary venorrhaphy for traumatic inferior vena cava (IVC) injury has been criticized because of the potential for stenosis, thrombosis, and embolism. A retrospective study was performed to evaluate the morbidity and outcome of this method. Thirty-eight patients at our institution had traumatic injuries to the IVC between 1994 and 1999. Thirty (79%) were from firearms, five (13%) from stab wounds, and three (8%) from blunt trauma. Six patients died in the emergency department. The remaining 32 patients underwent exploratory celiotomy with 23 survivors and nine intraoperative deaths for a mortality rate of 28 per cent (nine of 32). Vascular control was achieved by manual compression in 44 per cent and by local clamping directly above and below the injury in 38 per cent. All repairs were by primary venorrhaphy, and no patient was treated with patch angioplasty or venous reconstruction. Three patients had caval ligation. Follow-up IVC imaging in 11 patients revealed that the IVC was patent in eight, narrowed in two, and thrombosed below the renal veins in one. One patient developed a pulmonary embolus. The vast majority of traumatic injuries to the IVC can be managed by direct compression or local clamping and primary venorrhaphy. Direct repairs are associated with a low thrombosis and embolic complication rate.
Serum Amylase and Lipase Elevation is Associated with Intracranial Events
Authors: Liu Katherine J. M. , Atten Mary Jo , Lichtor Terry , Cho Moon Ja , Hawkins Debra , Panizales Evangeline , Busker John , Stone James , Donahue Philip E.
Published: November 2022

Serum amylase and lipase elevation has been observed in trauma patients and patients with traumatic intracranial bleeding. However, the causes of this elevation have not been clearly elucidated A further question remains as to whether other intracranial events are associated with such enzyme elevation as well. We retrospectively reviewed 75 patients consecutively admitted to Cook County Hospital Neurosurgical Intensive Care Unit over a 3-month period for trauma, infection, tumor, or other space-occupying lesions with an unstable condition or neurological deficit Eleven patients (15%) had elevated amylase and lipase levels. The patients were divided into two groups: Group I (n = 64) had normal and Group II (n = 11) had raised amylase and lipase levels [amylase 402 ± 444 U/L with normal ≤125 U/L and lipase 474 ± 313 U/L with normal ≤55 U/L]. All Group II patients suffered an intracranial event. Twenty-four Group I (38%) and 10 Group II (91%) patients required craniotomy ( P < 0.01). No patients had clinical or radiographic evidence of pancreatitis. In summary, intracranial events are associated with serum amylase and lipase elevation probably through centrally activated pathways. Because of the lack of diagnostic value, routine pancreatic enzyme monitoring should not be performed in this patient population.
What is Normal Intra-Abdominal Pressure?
Authors: Sanchez Noel C. , Tenofsky Patty L. , Dort Jonathan M. , Shen Luke Y. , Helmer Stephen D. , Smith R. Stephen
Published: November 2022

The causes and effects of increased intra-abdominal pressure and abdominal compartment syndrome have been well documented. However, there have been no large series to determine normal intra-abdominal pressure in hospitalized patients. The purpose of this study was to determine normal intra-abdominal pressure in randomly selected hospitalized patients and to identify factors that predict variation in normal intra-abdominal pressure. A total of 77 patients were prospectively enrolled between September 1998 and July 1999. Data obtained included patient demographics (i.e., age, gender, height, weight, and body mass index), reason for hospitalization and bladder catheterization, previous and current surgical status, comorbidities, and intra-abdominal pressures. Intra-abdominal pressure readings were obtained through an indwelling transurethral bladder (Foley) catheter. Data were analyzed by analysis of variance and multiple regression analysis. There were 36 females and 41 males with a mean age of 67.7 years. Average weight, height, and body mass index were 79.6 kg, 1.70 m, and 27.6 kg/m2, respectively. Mean intraabdominal pressure was 6.5 mm Hg (range 0.2–16.2 mm Hg). Body mass index was positively related to intra-abdominal pressure ( P < 0.0004). Gender, age, and medical and surgical histories did not significantly affect intra-abdominal pressure. However, using multiple regression analysis, a relationship between intra-abdominal pressure, body mass index, and abdominal surgery was discovered. Intra-abdominal pressure is related to a patient's body mass index and influenced by recent abdominal surgery. Thus, the normal intra-abdominal pressure can be estimated in hospitalized patients by using the derived equation. Knowledge of the expected intra-abdominal pressure can then by used in recognizing when an abnormally high intra-abdominal pressure or abdominal compartment syndrome exists.
Interferon alb Inhibits the Murine Melanoma Cell Line Cloudman S91 in Vivo but not in Vitro: A Model for Studying Tumor Cell-Cytokine Interactions
Authors: Habib Fahim A. , Lobocki Catherine , Ezhuthachan Rutu , Chelladurai Mohan , Preventza Ourania , Mittal Vijay K.
Published: November 2022

Interferon α2b has recently been shown to improve outcome in patients with metastatic malignant melanoma. The high-dose interferon therapy used is however associated with significant systemic adverse effects. These adverse effects are likely related to the multitude of actions of interferon which in addition to its antineoplastic effects also possesses antiviral and immunomodulating properties. Elucidation of the mechanism of the antiproliferative effects of interferon may allow for the development of agents that possess the antineoplastic properties while being devoid of the other effects that make interferon toxic. In the animal model developed for this study tumors in mice receiving interferon α2b grew at a slower rate and achieved a small final tumor volume (3040 ± 690 vs 1400 ± 314 mm3 for the control and treated groups respectively, P < 0.05). Furthermore the final tumor weight in the treated group was significantly smaller (1.50 ± 0.21 g vs 2.76 ± 0.46 g for the treated and control groups respectively; P = 0.036). The (3-[4,5-Dimethylthiazol-2-y]-2,5-diphenyltetrazolium bromide) (MTT) colorimetric assay failed to reveal any direct effects of interferon α2b on this murine melanoma cell line. This antiproliferative effect of interferon α2b was in addition found to be independent of alterations in the expression of the angiogenic cytokines vascular endothelial growth factor, basic fibroblast growth factor, and transforming growth factor β.
Acute Colonic Perforation Associated with Colorectal Cancer
Authors: Khan Sadaf , Pawlak Stephanie E. , Eggenberger John C. , Lee Chong S. , Szilagy Eric J. , Margolin David A.
Published: November 2022

Our purpose was to evaluate long-term outcome in patients presenting with acute colonic perforation in the setting of colorectal cancer. We conducted a retrospective review of 48 consecutive patients presenting with acute colonic perforation associated with colorectal cancer at a single institution. Patients presented either with free air or acute peritonitis. No patients with colonic obstruction were included. Forty-eight patients presented with colon perforation. Thirty-six had perforation at the tumor, 11 proximal to the tumor, and one distal to the primary tumor. Patients who perforated proximal to the tumor were older (74.5 ± 2 vs 64.7 ± 3; P < 0.04) and had a longer length of stay (46.8 ± 17 vs 11.6 ± 1 P < 0.001). Fourteen patients had stage II disease, 19 stage III, and 15 stage IV. Thirty-day mortality was 14 per cent (n = 7) with nine in-hospital deaths. Of 30-day survivors 29 (60%) had curative resection (21 with local perforation and nine with proximal perforation). Of these 14 received adjuvant chemotherapy. Eleven patients (33%) had either unresectable or metastatic disease on exploration. Mean follow-up was 21.5 months. Ten patients developed metastatic disease after potentially curative resections. Of these nine patients had perforations of the primary tumor. Three patients developed local recurrence and all had local tumor perforations. One-year survival was 55 per cent (n = 16). Five-year disease-free survival was 14 per cent (n = 4). There were no long-term survivors after perforation proximal to the tumor, although disease stage was comparable in both groups. We conclude that perforation proximal to a cancer is associated with a higher perioperative mortality and worse long-term outcome when compared with acute perforations at the site of the tumor. Long-term survival requires both aggressive management of the concomitant sepsis and definitive oncologic surgery.
Trimodality Therapy for Advanced Gallbladder Cancer
Authors: Sasson Aaron R. , Hoffman John P. , Ross Eric , Meropol Neal J. , Szarka Christine E. , Freedman Gary , Pinover Wayne , Pingpank James F. , Eisenberg Burton L.
Published: November 2022

We conducted a retrospective review of all patients who underwent surgical extirpation for stage IN, stage IV, or recurrent carcinoma of the gallbladder. Between 1991 and 1999 ten patients underwent surgical resection for advanced gallbladder cancer. All patients received adjuvant therapy either pre- or postoperatively. Radiotherapy was used in all patients and chemotherapy in 90 per cent of patients. Two patients subsequently underwent resection for locally recurrent disease. An additional patient with stage II disease initially was also treated surgically for a local recurrence. Surgical management involved cholecystectomy and resection of various amounts of liver surrounding the gallbladder bed and regional lymphadenectomy. Contiguously involved structures were resected en bloc. Resection of recurrent disease included excision of all gross tumor. The median overall survival excluding the one 30-day mortality was 53.6 months (range 8–73 months). Four patients have survived 4 or more years, and currently four patients are alive and disease free at 73, 49, 33, and 8 months. Median disease-free interval after each resection of recurrent disease was 13.8 months (range 4–28 months). We conclude that trimodality therapy in selected patients with stage III, IV, or recurrent carcinoma of the gallbladder is possible and may result in prolonged survival.
Open versus Percutaneous Dilatational Tracheostomy: Efficacy and Cost Analysis
Authors: Grover Amelia , Robbins James , Bendick Phil , Gibson Maureen , Villalba Mario
Published: November 2022

The economic advantages of percutaneous dilatational tracheostomies versus open tracheostomies in the operating room have been thoroughly evaluated. We are now reporting our comparison of the costs and charges of percutaneous dilatational tracheostomies with those of open bedside tracheostomies at our institution. The current literature comparing the two open techniques and the percutaneous method of placing tracheostomies was reviewed and the charges and costs for these procedures at our institution were compared. Patients were placed into one of three groups for analysis: open tracheostomies in the operating room (Group I), open tracheostomies in the intensive care unit (Group II), and percutaneous dilatational tracheostomies in the intensive care unit (Group III). Based on our own experience and a literature review it is evident that all three approaches to tracheostomies are safe. Economic analysis showed a savings of $180 in cost per procedure and a $658 savings in charges per procedure for the open method at the bedside when compared with the percutaneous method at the bedside. The professional fee for bronchoscopy was not included in this calculation; including this would lead to greater savings with the open method over the percutaneous method. Open tracheostomy in the operating room increased costs over the bedside procedure by $2194 and increased charges by $2871. For the 150 to 180 tracheostomies done each year at our institution utilization of the open technique at the bedside results in a cost savings of approximately $31,500 and a charge savings of $109,000 compared with the percutaneous dilatational tracheostomy. Both the open bedside and percutaneous dilatational methods are reasonable and safe options. However, the open bedside tracheostomy is a better utilization of resources and is more cost effective, and it is the procedure of choice at our institution.
Refractory Renal Hyperparathyroidism: Clinical Features and Outcome of Surgical Therapy
Authors: Mchenry Christopher R. , Wilhelm Scott M. , Icanati Edmond
Published: November 2022

Despite improvements in medical management parathyroidectomy has an important role in treatment of refractory renal hyperparathyroidism (HPT). The medical records of all patients who underwent parathyroidectomy from 1991 through 2000 were reviewed to determine the clinical and laboratory features and outcomes of treatment in patients with renal versus primary HPT. Twenty-one of 92 patients who underwent parathyroidectomy had renal HPT with a mean age of 47 ± 3 years compared with 56 ± 2 years for patients with primary HPT ( P < 0.05). Clinical manifestations included osteodystrophy (19), pruritus (six), extraosseous calcification (three), and calciphylaxis (one). Parathyroid hormone, phosphorus, and alkaline phosphatase levels and weights of excised glands were higher in renal versus primary HPT ( P < 0.05). Supernumerary glands were found in three patients (14%) with renal HPT and none of nine patients with primary parathyroid hyperplasia. After surgical therapy persistent or recurrent HPT occurred in three (14%) patients with renal and one (1.4%) patient with primary HPT ( P < 0.05). Postoperative hypocalcemia occurred in 20 (95%) patients with renal HPT all of whom required intravenous calcium, compared with 25 (35%) patients with primary HPT ( P < 0.05) of whom only three (4%) required intravenous calcium ( P < 0.05). In contrast to those with primary HPT patients with renal HPT are younger and more likely to have severe osteodystrophy, postoperative hypocalcemia, and persistent or recurrent HPT.
Perioperative Factors as Predictors of Operative Mortality and Morbidity in Pneumonectomy
Authors: Joo J.B. , Debord James R. , Montgomery Charles E. , Munns James R. , Marshall J. Stephen , Paulsen J. Kevin , Anderson Richard C. , Meyer Lynn E. , Estes Norman C.
Published: November 2022

Pneumonectomy for lung cancer is associated with significant morbidity and mortality. Risk factors for the morbidity and mortality have been reported, but consistent conclusive data are undetermined. Current accepted 30-day mortality rates for pneumonectomy range from 7 to 11 per cent. The objective of this study is to determine whether various perioperative factors can serve as predictors of morbidity and mortality in pneumonectomy patients and to review outcome data on patients undergoing pneumonectomy for lung cancer. A total of 105 patients undergoing pneumonectomy for lung cancer from 1988 through 1998 are studied in a retrospective chart review. The main outcome measure is the 30-day operative mortality and morbidity. Complications occurring in 10 per cent or more of the patients included atrial fibrillation (33.3%), respiratory failure (23.8%), pneumonia (21.9%), and bronchopleural fistula (12.4%). The 30-day mortality rate was 10.5 per cent (11 deaths). By Fisher's exact test for Chi-square only three statistically significant mortality factors were identified: respiratory failure ( P < 0.021), sepsis ( P < 0.008), and male sex ( P < 0.031); respiratory failure, sepsis, and sex were predictors of death. Significant correlation could not be made to predict postoperative morbidity. Overall long-term clinical outcome for pneumonectomy as lung cancer treatment was poor. Clinical judgment remains an essential factor when considering pneumonectomy as an option for lung cancer treatment.
Objective Structured Clinical Examination Technical Skill Stations Correlate More Closely with Postgraduate Year Level than Do Clinical Skill Stations
Authors: Cerilli Gregory J. , Merrick Hollis W. , Staren Edgar D.
Published: November 2022

Validity of an examination format is supported by its ability to distinguish levels of training among examinees. The Objective Structured Clinical Examination (OSCE) is a developing format generally composed of various types of task-oriented stations used to evaluate clinical skills of students and residents. The ideal composition of OSCE stations to maximize validity has not been determined. We examined the relative correlation between selected types of stations and level of resident postgraduate year (PGY). A 12-station OSCE was administered to surgical residents of all PGY levels at a university program. Individual station scores were correlated with PGY level. The overall correlation of the total examination score with PGY level was good (R = 0.681). Technical skill stations exhibited a significantly greater correlation with PGY level (0.679 vs 0.203) as compared with clinical skill stations ( P < 0.05). These data suggest that technical skill evaluation is more sensitive in distinguishing level of training of surgical residents than is clinical skill evaluation.
Telemedicine in Vascular Surgery: Does it Work?
Authors: Endean Eric D. , Mallon Lawrence I. , Minion David J. , Kwolek Christopher J. , Schwarcz Thomas H.
Published: November 2022

Telemedicine (TM) using closed-circuit television systems allows specialists to evaluate patients at remote sites. Because an integral part of the vascular examination involves palpation of peripheral pulses the applicability of TM for the evaluation of vascular surgery patients is open to question. This study was carried out to test the hypothesis that TM is as effective as direct patient examination for the development of a care plan in vascular patients. Sixty-four vascular evaluations were done in 32 patients. The patients presented with a variety of vascular problems and were seen in regularly scheduled rural outreach vascular clinics. Two faculty vascular surgeons evaluated each patient; one was on site and the second, using TM, remained at the medical center. Each surgeon was blinded to the other's findings. The TM physician was aided by a nonphysician assistant, who obtained blood pressures, utilized a continuous-wave Doppler probe, positioned the patient, and operated the TM equipment. The results of each surgeon's evaluations were compared. Patient and physician satisfaction with the TM evaluation was appraised by questionnaires. Eight patients were seen for initial evaluations; 24 patients were seen for follow-up visits. Patients were seen with a variety of diagnoses, including aneurysm (seven), cerebrovascular disease (five), lower extremity occlusive disease (13), multiple vascular problems (three), and other disease (four). The average duration for the TM and on-site evaluations were 20.6 ± 1.4 and 19.0 ± 1.3 minutes, respectively ( P = not significant). Physician concordance, as determined by treatment recommendations, was the same in 29 (91%) patients. Physician confidence in the ability to obtain an accurate history via TM was rated as excellent in 97 per cent; confidence in the TM physical examination was rated as excellent in 70 per cent. All patients rated the TM evaluation as the “same as” or “better than” the on-site examination, and all indicated a preference for being seen locally using TM as opposed to traveling to a regional medical center. We conclude that the TM evaluation of vascular patients is accurate and is as effective as on-site evaluations for a variety of vascular problems. Important adjuncts to enhance the success of a TM evaluation are physician experience with the technology and the presence of a knowledgeable on-site assistant. This technology can be easily adapted to other clinical situations.
Laparoscopic versus Conventional Live Donor Nephrectomy: Experience in a Community Transplant Program
Authors: Hawasli Abdelkader , Boutt Anthony , Cousins Geoffrey , Schervish Edward , Oh Henry
Published: November 2022

Fifty-nine consecutive patients underwent live donor nephrectomy for transplantation. Twenty-nine patients (Group I) had open kidney procurement, and 30 patients (Group II) had laparoscopic procurement. The mean operative time in Group I was 2:30 hours (range 1:55–2:59), whereas in Group II it was 3:01 hours (1:54–5:21). All kidneys functioned immediately after transplantation. The average warm ischemia time was not calculated in Group I; it was 3.9 minutes (2–15) in Group II. Intraoperative complications occurred in two patients in Group II. One patient had bleeding from an accessory renal artery. The second patient had a tear in the splenic capsule. No ureteral complications occurred in either group. Postoperatively one patient in Group I developed incisional hernia, one developed pneumothorax, and two developed atelectasis. In Group II one patient developed pancreatitis, one developed flank ecchymosis, and two had suprapubic wound hematomas. Using the laparoscopic approach the hospital stay decreased from 4.1 to 1.27 days (69%) ( P < 0.001) and return to work decreased from 28.4 to 14.8 days (49%) ( P < 0.01). Live donation increased by 67 per cent. We conclude that the laparoscopic procurement of kidneys for transplantation compares well with the open method. It offers several advantages that may increase the living donor pool.
Adult Intussusception Due to a Malignant Polyp: A Case Report
Authors: Dener Cenap , Bozoklu Serhasan , Bozoklu Ayça , Özdemir Arif
Published: November 2022

Intussusception is primarily a disease of childhood; only about 5 to 10 per cent of cases occur in adults. In contrast to childhood intussusception 90 per cent of adults have an associated pathologic process, usually a malignant lesion. Adult cases do not have the classical symptoms and diagnosis may be difficult. CT scan and barium studies are the most useful diagnostic methods. We report a very rare case of adult ileocecocolic intussusception caused by a pedunculated malignant polyp of the cecum and review the clinical features of intussusception.
Blood Pressure Effects of Thoracic Gunshot Wounds: The Role of Bullet Image Diameter
Authors: Marraccini John V. , Lentz Kimberly , Mckenney Mark G.
Published: November 2022

Differences in handgun bullet diameter, expansion, and penetration (no exit) versus perforation (with exit) may be the cause of variable blood pressure effects after thoracopulmonary injury. Forty nonlethal isolated gunshot wounds of the thorax were evaluated excluding wounds of the heart, great vessels, and spinal cord. Chest radiographs were assessed for bullet base diameter, bullet expansion, and wound length. Large bullets were defined as having radiographic base images of 9 mm or more in diameter. Systolic blood pressures were compared between penetrating large and small bullet groups and with perforating wounds. Response times and demographics were compared. Wounds caused by large bullet penetration resulted in lower initial systolic blood pressures than wounds caused by small bullet penetration (98 vs 125 mm Hg, P < 0.05). The average age, transport time, and wound length were similar among the bullet groups. We conclude that penetrating thoracopulmonary wounds caused by large bullets resulted in lower initial systolic blood pressure.
Secondary Hyperparathyroidism: Evidence for an Association with Papillary Thyroid Cancer
Authors: Klyachkin Michael L. , Sloan David A.
Published: November 2022

The association between primary hyperparathyroidism and nonmedullary thyroid malignancies is well known. There is also, however, some evidence for an association between secondary hyperparathyroidism (SHPT) and thyroid cancer. We report three patients in whom invasive papillary thyroid carcinoma (PTC) was diagnosed before (one case) or at the time of (two cases) parathyroidectomy for SHPT. Three women (ages 23, 54, and 64 years) presented with bone pain and pruritis typical of SHPT. All three patients had biopsy-proven parathyroid bone disease and elevated parathormone levels (664, 1674, and 2051 pg/mL). All underwent subtotal parathyroidectomy and total thyroidectomy without complications. Pathology revealed diffuse parathyroid hyperplasia with multifocal invasive papillary thyroid carcinoma (two cases) and follicular variant of papillary thyroid carcinoma (one case). Two cases were associated with metastatic disease to local lymph nodes. The patients received adjuvant radioactive 131I, and remained tumor free 24 to 36 months after surgery with complete resolution of SHPT. We conclude: 1) PTC may accompany SHPT, 2) PTCs associated with SHPT may be locally aggressive although usually they are early tumors, 3) surgeons need to have an index of suspicion for thyroid tumor when operating on patients with SHPT, and 4) routine removal of the thymus as part of the operation for SHPT may have a secondary benefit in diagnosing PTC in the occasional patient.
Intraductal Papillary-Mucinous Tumor of the Pancreas: Assessing the Grade of Malignancy from Natural History
Authors: Yamaguchi Koji , Sugitani Atsushi , Chijiiwa Kazuo , Tanaka Masao
Published: November 2022

Intraductal papillary-mucinous tumor of the pancreas is a spectrum of conditions ranging from benign to malignant, and very few papers have referred to the natural history of this disease. In this communication the indicators of malignancy were examined from a viewpoint of natural history. Follow-up computed tomographies (CTs) more than 6 months after the diagnosis were reviewed in 17 Japanese patients with intraductal papillary-mucinous tumor of the pancreas. They were divided into two groups by the presence or absence of morphological progressive changes by the follow-up CTs, and the clinicopathological features were compared between the two groups to examine possible malignant indicators. The 17 patients consisted of seven patients in the no-change group and ten in the progressive group. The distribution of the patients was not different with regard to age; gender; or presence or absence of pancreatitis, diabetes mellitus, or unique findings of the ampulla of Vater between the two groups. The dilatation of the main pancreatic duct (≥3 mm) was more frequent in the progressive group: (eight of ten patients; 80%) than in the no-change group (two of seven patients; 29%) ( P = 0.03). Six (86%) of the seven tumors in the no-change group were located in the branch duct, whereas five (50%) of the ten in the progressive group were situated in the main pancreatic duct. Histopathologic diagnoses of the resected specimens of the four in the no-change group examined were intraductal papillary-mucinous adenoma in three and adenoma with moderate dysplasia in one, whereas the diagnoses in the six in the progressive group examined were adenoma in two, adenoma with moderate dysplasia in two, and carcinoma (invasive) in two. The patients with intraductal papillary-mucinous tumor of the pancreas with a dilatation of the main pancreatic duct at the time of diagnosis should be followed up more carefully than those without dilatation. Once progressive morphological changes are detected by the follow-up CTs surgical resection should be considered because of possible malignancy.
Abdominal Wall Penetration by a Police “Bean Bag”
Authors: Olivas Terry , Jones Bruce , Canulla Marco
Published: November 2022

Police departments across the country now have at their disposal a “nonlethal” weapon known as a “bean bag” shotgun. The bean bags, which come loaded in standard shotgun shells, are missiles intended to disable dangerous suspects without having to resort to lethal force. They were specifically designed not to create penetrating injuries. Here we present a case of abdominal wall penetration by a police bean bag. To our knowledge this is the first such reported case of this type of injury.
Should Trauma Surgeons Render Definitive Vascular Repair in Peripheral Vascular Injuries?
Authors: Porter John M. , Ivatury Rao R.
Published: November 2022

Our hypothesis is that in an established Level I trauma center general trauma surgeons should repair peripheral vascular injuries even in stable patients when there is time for a vascular consult. We reviewed all penetrating peripheral vascular injuries in stable patients operated on by nine experienced general trauma surgeons (1993–1996). Outcome measures were amputation, nerve damage, and vascular complications. There were 43 patients with 44 peripheral vascular injuries identified. Sixty per cent were from stab wounds. There were 27 arterial injuries (carotid four, subclavian one, vertebral two, axillary three, brachial eight, ulnar one, radial two, femoral five, and anterior tibial one). There were three venous injuries (one each subclavian, axillary, and popliteal). There were 14 combined injuries (vertebral two, femoral nine, and popliteal three). There were no mortalities. Morbidity was limited to patients with lower extremity injuries. In the nine patients with combined femoral vessel injury there were three complications (nerve damage, thrombosed arterial repair, and thrombosed venous repair). In the four patients with popliteal venous injuries there were two complications, both venous thrombosis. Our early arterial patency rate was 97.6 per cent. These data support the hypothesis that general surgeons with trauma experience can provide effective treatment of peripheral vascular injuries. The significance of these findings in improving the image of trauma surgery as a career is discussed.
Long-Term Results of Hepaticojejunostomy for Hepatolithiasis
Authors: Kusano Toshiomi , Isa Tsutomu , Muto Yoshihiro , Otsubo Mitsuji , Yasaka Takahiro , Furukawa Masato
Published: November 2022

The results of a hepaticojejunostomy as a biliary-enteric bypass for benign disease are usually excellent. On the other hand, hepatolithiasis features a high rate of residual and recurrent stones with cholangitis after surgery. This study aims to evaluate the long-term results of a hepaticojejunostomy for hepatolithiasis regarding both the degree of the occurrence of postoperative cholangitis and the outcome. The clinical records of 159 patients with hepatolithiasis who underwent surgical treatment over a 23-year period were also retrospectively reviewed. Ninety-four of 159 patients underwent a hepatecetomy and 65 patients were subjected to liver-preserving surgery by means of intra- and postoperative endoscopic lithotripsy. In addition 72 patients underwent a hepaticojejunostomy. The rate of residual or recurrent stones was 31.4 per cent after complete stone removal. Twenty-two (30.6%) of the 72 patients developed some kind of cholangitis. This rate was significantly higher than that (three of 87 patients) of the non-biliary-enteric anastomosis group regarding the occurrence of biliary complications. We conclude that the use of a hepaticojejunostomy for patients with possible residual stones or intrahepatic bile duct lesions remains controversial.
Abdominal Compartment Syndrome with Massive Lower-Extremity Edema Caused by Colonic Obstruction and Distention
Authors: Blevins David V. , Khanduja K.S.
Published: November 2022

Abdominal compartment syndrome is a well-described condition in which increased intraabdominal pressure causes various physiologic derangements with adverse effects on cardiac, pulmonary, and renal function. A patient presented with radiation-induced distal colonic obstruction, abdominal distention, and severe bilateral leg edema. We performed a diverting transverse loop colostomy as treatment for her obstruction. This resulted in massive, spontaneous diuresis with complete resolution of her lower-limb edema. Abdominal compartment syndrome due to colonic obstruction can contribute to the development of lower-extremity edema. Colon decompression with reduction of intra-abdominal pressure can lead to resolution of edema in this situation.
Outcome of Surgical Treatment of Chronic Pancreatitis Associated with Sphincter of Oddi Dysfunction
Authors: Rios Gloria A. , Adams David B.
Published: November 2022

The clinical management of patients with chronic pancreatitis (CP) associated with sphincter of Oddi dysfunction (SOD) presents many challenges. The aim of this study was to evaluate patient outcome after surgical management of CP associated with SOD intractable to medical management. The records of patients with CP and SOD who underwent surgical treatment between 1994 and 1998 were retrospectively reviewed and analyzed. Manometry of biliary and pancreatic ducts was performed. Basal pressures were considered abnormal if ≥40 mm Hg for at least 30 seconds. Endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, and clinical criteria were utilized in the diagnosis of CP. Quality-of-life issues were assessed. Twenty-nine patients were identified (21 women and eight men) with a mean age of 43.3 years (range 24–54). Mean basal biliary and pancreatic sphincter pressures were 155.1 and 90.4 mm Hg respectively. Chronic pancreatitis was graded as mild in nine patients, moderate in six, severe in two, and normal or equivocal in 12 patients according to the Cambridge classification. A Whipple procedure was performed in 17 (59%) patients, lateral pancreaticojejunostomy in nine (31%), and distal resections or a combination of procedures in three (10%). The morbidity and mortality rates were 21 and 0 per cent respectively. Mean follow-up was 30 months (range 3–48). Pain relief ranging from fair to excellent was seen in 83 per cent of patients with pain scores decreasing from an average of 9 (scale 1–10) before surgery to 3 postoperatively. Seventy per cent maintained their weight, 45 per cent continued to require pancreatic enzyme supplementation, and there were no changes in the status of diabetes. Rehospitalizations for recurrent pancreatitis or persistent pain were necessary in 24 per cent of patients. Surgical management of patients with CP and SOD who fail medical management is safe and effective in most patients. Operative morbidity and mortality are low, and the majority of patients have improvement in pain, although some require rehospitalization for recurrent pancreatitis and chronic pain.