bluuebunny/crossref_metadata_2025 huggingface dataset:
Dynamic Wound Closure for Decompressive Leg Fasciotomy Wounds
Authors: Singh Niten , Bluman Eric , Starnes Benjamin , Andersen Charles
Published: June 2020

Decompressive fasciotomy for preservation of lower extremity function and salvage is an essential technique in trauma. The wounds that result from the standard two incision four-compartment leg fasciotomy are often accompanied by a wide soft tissue opening that in the face of true compartment syndrome are often impossible to close in a delayed primary fashion. We describe a technique using a device that allows for dissipation of the workload across the wound margin allowing for successful delayed primary closure. Consecutive patients who presented to the 28th Combat Support Hospital in Baghdad, Iraq with a diagnosis of compartment syndrome of the leg, impending compartment syndrome of the leg, or compartment syndrome of the leg recently treated with fasciotomies were followed. All patients underwent placement of the Canica dynamic wound closure device (Canica, Almonte, ON, Canada). Eleven consecutive patients treated at a combat support hospital in support of Operation Iraqi Freedom underwent four-compartment fasciotomies for penetrating injuries. There were five patients that underwent a vascular repair [three superficial femoral artery (SFA) injuries and two below knee popliteal artery injuries] and six patients that had orthopedic injuries (three comminuted tibial fractures, two fibula fractures, and one closed pilon fracture). Patients returned to the operating room within 24 hours for washout and wound inspection. Mean initial wound size was 8.1 cm; mean postplacement size was 2.7 cm; average time to closure was 2.6 days. All patients were able to undergo primary wound closure of the medial incision and placement of the Canica device over the lateral incision. Ten of the 11 patients (91%) could be closed in delayed primary fashion after application of the device. In our series of patients with penetrating wartime injuries and compartment syndrome of the leg we have found the use of this dynamic wound closure device to be extremely successful and expedient.
Car Surfing: Case Studies of a Growing Dangerous Phenomenon
Authors: Clark Steven , Mangram Alicia , Dunn Ernest
Published: June 2020

Car surfing is a dangerous new pastime for American youth. Car surfing is an activity that is defined as standing (or lying) on a vehicle while it is being driven. This activity frequently results in severe injuries that often require significant surgical intervention. Despite its destructive nature, however, there are many Internet sites that encourage this behavior and view it as amusing. As a result, car surfing is becoming increasingly popular. We conducted a retrospective chart review of all patients injured as a result of car surfing over the last 4 years at our Urban Level II trauma center. Data collected included Injury Severity Score (ISS), Revised Trauma Score (RTS), age, gender, injury pattern, surgical intervention, and length of stay. Eight car surfers were identified. The average age was 17. The average Revised Trauma Score was 6.8 with an average Injury Severity Score of 16.9. Five patients were admitted to the intensive care unit. Four of these five patients needed to be intubated for ventilatory support. Five of the eight patients had significant intracranial injuries. Two patients had epidural hematomas that required evacuation. Two other patients had subdural hematomas that were treated nonoperatively, and one patient had a subarachnoid hemorrhage that was also treated nonoperatively. Four of the eight patients required surgical intervention. There were no deaths in this study. Car surfing leads to severe injuries that can result in significant morbidity. American youth have access to Internet sites that project this activity as an acceptable behavior. Five of our eight patients had a significant intra-cranial injury. Trauma surgeons need to be more aware of this injury phenomenon.
Blast Injury in a Civilian Trauma Setting is Associated with a Delay in Diagnosis of Traumatic Brain Injury
Authors: Bochicchio Grant V. , Lumpkins Kimberly , O'Connor James , Simard Marc , Schaub Stacey , Conway Anne , Bochicchio Kelly , Scalea Thomas M.
Published: June 2020

High-pressure waves (blast) account for the majority of combat injuries and are becoming increasingly common in terrorist attacks. To our knowledge, there are no data evaluating the epidemiology of blast injury in a domestic nonterrorist setting. Data were analyzed retrospectively on patients admitted with any type of blast injury over a 10-year period at a busy urban trauma center. Injuries were classified by etiology of explosion and anatomical location. Eighty-nine cases of blast injury were identified in 57,392 patients (0.2%) treated over the study period. The majority of patients were male (78%) with a mean age of 40 ± 17 years. The mean Injury Severity Score was 13 ± 11 with an admission Trauma and Injury Severity Score of 0.9 ± 0.2 and Revised Trauma Score of 7.5 ± 0.8. The mean intensive care unit and hospital length of stay was 2 ± 7 days and 4.6 ± 10 days, respectively, with an overall mortality rate of 4.5 per cent. Private dwelling explosion [n = 31 (35%)] was the most common etiology followed by industrial pressure blast [n = 20 (22%)], industrial gas explosion [n = 16 (18%)], military training-related explosion [n = 15 (17%)], home explosive device [n = 8 (9%)], and fireworks explosion [n = 1 (1%)]. Maxillofacial injuries were the most common injury (n = 78) followed by upper extremity orthopedic (n = 29), head injury (n = 32), abdominal (n = 30), lower extremity orthopedic (n = 29), and thoracic (n = 19). The majority of patients with head injury [28 of 32 (88%)] presented with a Glasgow Coma Scale score of 15. CT scans on admission were initially positive for brain injury in 14 of 28 patients (50%). Seven patients (25%) who did not have a CT scan on admission had a CT performed later in their hospital course as a result of mental status change and were positive for traumatic brain injury (TBI). Three patients (11%) had a negative admission CT with a subsequently positive CT for TBI over the next 48 hours. The remaining four patients (14%) were diagnosed with skull fractures. All patients (n = 4) with an admission Glasgow Coma Scale score of less than 8 died from diffuse axonal injury. Blast injury is a complicated disease process, which may evolve over time, particularly with TBI. The missed injury rate for TBI in patients with a Glasgow Coma Scale score of 15 was 36 per cent. More studies are needed in the area of blast injury to better understand this disease process.
Panperitonitis Caused by Gangrene of the Urinary Bladder: Report of a Successfully Treated Case
Authors: Fujiwara Shozo , Noguchi Tsuyoshi , Noguchi Takuya , Emoto Akio , Tasaki Yoshihisa
Published: June 2020

The patient was a 74-year-old woman with Parkinson's disease who had a past history of total hysterectomy for uterine myoma. She was admitted for a femoral neck fracture and treated conservatively. From the third day of the illness, the patient experienced increased urinary frequency and constant urge to urinate. On the seventh day, the patient developed peritonitis and underwent emergency surgery. Laparotomy confirmed a dark greenish malodorous abscess in the abdominal cavity. The bladder was necrotic and perforated, and the patient was accordingly diagnosed with panperitonitis caused by bladder gangrene. Because almost the entire bladder exhibited full-layer necrosis, it was determined that bladder preservation would not be possible, and total cystectomy, bilateral ureterocutaneostomy, and abdominal drainage were performed. Postoperatively, residual intra-abdominal abscess was present, but this resolved with drainage and antibiotic administration. Here, we present this patient who survived extremely rare pan-peritonitis caused by bladder gangrene.
Unresectable Hepatocellular Carcinoma with a Solitary Metastasis to the Mandible
Authors: Li Ryan , Walvekar Rohan R. , Nalesnik Michael A. , Gamblin T. Clark
Published: June 2020

Hepatocellular carcinoma (HCC) continues to pose a worldwide burden on health resources with an occurrence of 1.4 million cases annually. It represents the fifth most common cancer in men and eighth most common in women worldwide. Eighty per cent of patients have a background cirrhotic liver, most commonly in the United States, resulting from chronic hepatitis C infection, whereas alcoholism also commonly contributes to the development of cirrhosis. Fifty per cent of patients diagnosed with HCC present with metastatic disease. Sites of metastasis commonly include the lungs, vertebral bones, and abdominal lymph nodes. Metastasis to the oral region is very rare. We report a 55-year-old man with metastatic HCC to the mandible. The patient was previously diagnosed with unresectable HCC and had undergone six cycles of chemoembolization therapy. Although the lesion remained stable in size, he did not qualify for liver transplantation because of active alcohol use. He presented to the emergency room for evaluation of recent-onset jaw pain. There was no history of trauma and an oral examination did not reveal any mucosal lesions. Mild swelling and tenderness of the right jaw was noted, and a subsequent CT scan revealed a right-sided mass centered around a fracture of the body of the mandible and surrounded by the masseter muscle. A biopsy of the mass revealed a metastatic hepatocellular carcinoma and a CT scan of the chest, abdomen, and pelvis confirmed it to be a solitary metastasis. The patient underwent surgical resection of a segment of the right mandible and the metastatic tumor. He continues to receive regional chemoembolization and is currently pain-free. Solitary metastasis to the mandible in the setting of HCC is exceedingly rare. Fine needle aspiration biopsy of the lesion with immunohistochemical analysis is useful in characterizing the lesion and identifying the primary site. Radiotherapy has been used to palliate mandibular metastases; however, surgical intervention proved to be very effective in managing this patient's disease.
Article Commentary: Managing Dissections of the Thoracic Aorta
Authors: Wong Daniel R. , Lemaire Scott A. , Coselli Joseph S.
Published: June 2020

Thoracic aortic dissection is associated with substantial morbidity and mortality, and it requires timely and accurate diagnosis and treatment. Long-term antihypertensive therapy remains critical for the treatment of this disease. Surgical intervention, although still a formidable undertaking, has evolved to better address both acute and chronic dissection, and the results have improved. Basic and clinical research, as well as technological advances, have increased our understanding of this challenging disease state.
Use of rFVIIa in the Trauma Setting–Practice Patterns in United States Trauma Centers
Authors: Horton John D. , Dezee Kent J. , Wagner Michel
Published: June 2020

Much excitement has been generated regarding the off label use of recombinant factor VIIa (rFVIIa) in the severely injured trauma patient. The purpose of our study is 3-fold: 1) describe the type of centers that use rFVIIa, 2) determine which centers use the drug more frequently, and finally 3) investigate how this drug is being administered at trauma centers. A survey was mailed or e-mailed to 435 trauma centers (Level I and II) throughout the nation. One hundred fifty-six surveys were returned. American College of Surgeons (ACS) verification and trauma Level I designation were independent predictors of rFVIIa use (odds ratio [OR] 3.74 and 5.40, P < 0.05). High users of rFVIIa were defined as those centers that had above median usage of the drug. Level I centers accounted for 67 per cent of the high users. Only the number of fellowship-trained trauma surgeons and trauma volume predicted high usage of rFVIIa (OR 1.38 and 14.09, P < 0.05). Trauma volume predicted whether or not Factor VII users implemented a protocol based approach to administration of the drug (OR 6.57, P < 0.05). Most protocols incorporated packed red blood cells (74%) before giving rFVIIa. The dose of 90 mcg/kg was exceeded in 34 per cent of centers, and 3 per cent used the 200 mcg/kg dose. High volume Level I trauma centers use rFVIIa more frequently and are more likely to use a systematic approach to its administration. However, there is no standardized approach to rFVIIa administration in United States trauma centers.
Boerhaave's Syndrome following Chiropractic Manipulation
Authors: Sozio Margaret S. , Cave Matt
Published: June 2020

This report documents the first known case of esophageal rupture occurring after chiropractic manipulation of the thoracic and lumbar spine for the treatment of back pain. Physicians should be aware of this potentially lethal complication of chiropractic medicine. The images are presented for educational purposes.
Hyperparathyroidism and Vitamin D Deficiency after Laparoscopic Gastric Bypass
Authors: Clements Ronald H. , Yellumahanthi Kishore , Wesley Mary , Ballem Naveen , Bland Kirby I.
Published: June 2020

Hyperparathyroidism (HPT) can occur after gastric bypass because of the alteration in vitamin D and calcium absorption. Adequate serum vitamin D concentrations have not been clearly defined in this patient population. Vitamin D (Vit D) and parathyroid hormone (PTH) were assessed 1 year after laparoscopic gastric bypass (LGB). The prevalence of HPT and Vit D deficiency were determined and their association was evaluated using Fisher's exact test. Ninety-three patients (aged 44 ± 1.1 years, 49.6 ± 0.67 kg/m2 body mass index, 79.6% female, 69.6% white) were evaluated. The prevalence of Vit D deficiency (less than 20 ng/mL) and HPT (greater than 65 pg/mL) was 23.6 per cent (n = 22) and 25.7 per cent (n = 28), respectively. Among patients with HPT, only eight of 28 (28.6%) had Vit D deficiency, and of those with Vit D deficiency, only eight of 22 (36.4%) had HPT. There was a weak inverse correlation (r = –0.37) between PTH and Vit D. Blacks are at higher risk for Vit D deficiency. There was no significant association between Vit D deficiency and HPT, Vit D deficiency and Roux limb length, or HPT and Roux limb length. After LGB, Vit D deficiency and hyperparathyroidism occur commonly. Body mass index and Roux limb length are not associated with these two conditions, but racial differences do exist. There is a weak inverse correlation between Vit D and PTH. Further research is needed to elucidate the causes, treatments, and significance of HPT after LGB.
Article Commentary: Zollinger–Ellison Syndrome: A Personal Perspective
Authors: Ellison E. Christopher
Published: June 2020

The odyssey of Zollinger-Ellison Syndrome is one of the most interesting in surgery. From the initial recognition of two patients with severe peptic ulcer disease in 1955 sprung an international dialogue on this unique disease culminating in discovery that gastrin was the hormone secreted by these pancreatic and duodenal tumors. The impact was the birth of a new area of science, “gastrointestinal endocrinology.” Initially, surgeons were challenged by the complexity of the patients and the need to perform total gastrectomy to prevent death from complications of the severe ulcer disease. Later, after the discovery of proton pump inhibitors, total gastrectomy was no longer needed and the surgeon could focus treatment on tumor removal added by radioimmunoassay for gastrin and new imaging modalities. Today, we recognize that all gastrinomas have malignant potential; early surgical removal can reduce the incidence of metastases and improve survival, independent of biochemical cure, in both sporadic and familial forms of the disease.
Laparoscopic Nissen Fundoplication Ameliorates Symptoms of Reflux, Especially for Patients with Very Abnormal DeMeester Scores
Authors: Ross Sharona B. , Villadolid Desiree , Paul Harold , Al-Saadi Sam , Gonzalez Javier , Cowgill Sarah M. , Rosemurgy Alexander
Published: June 2020

Intuitively, more severe acid reflux causes more severe symptoms. This study was undertaken to correlate preoperative DeMeester scores with symptoms before and after laparoscopic Nissen fundoplication. Before fundoplication, all patients with gastroesophageal reflux disease underwent 24 to 48 hour pH testing. Before and after fundoplication, the frequency and severity of reflux symptoms were scored using a Likert scale. Four hundred and eighty-one patients underwent fundoplication and were followed for a mean of 32 months. The preoperative median DeMeester score was 41 (range 14.8 to 361.5). Before fundoplication, DeMeester scores correlated with severity of gastroesophageal reflux disease symptoms (Spearman regression analysis, P < 0.05 for all). Postoperatively, all symptom scores improved (Wilcoxon matched pairs test, P < 0.05 for all). After fundoplication, preoperative DeMeester scores did not correlate with the frequency or severity of symptoms. For patients with excessive acid reflux, reflux severity impacts the frequency and severity of symptoms before fundoplication. Laparoscopic Nissen fundoplication improves the frequency and severity of all reflux symptoms. The severity of preoperative reflux does not impact the frequency or severity of symptoms after fundoplication. Relief of excessive acid reflux, regardless of severity or degree ( i.e., DeMeester scores), ameliorates symptoms of acid reflux thereby encouraging fundoplication, especially for patients with very abnormal DeMeester scores.
The Practice of Pancreatic Resection after Roux-en-Y Gastric Bypass
Authors: Barbour John R. , Thomas Bryan N. , Morgan Katherine A. , Byrne T. Karl , Adams David B.
Published: June 2020

The morbid obesity epidemic in the United States has resulted in increasing numbers of patients who have undergone Roux-en-Y gastric bypass who require surgical management of nonbariatric disorders. When pancreatic resection is indicated in bariatric patients, consideration of the altered foregut anatomy can be applied to the principles of pancreatic resection to foster effective techniques that minimize operative complications. A retrospective review and analysis of bariatric patients who underwent pancreatic resection at the Medical University of South Carolina Digestive Center over a 2-year period (2006 to 2007) was conducted to assess indications for operation, operative techniques, and postoperative outcome in patients with previous Roux-en-Y gastric bypass. There were five patients (four female, one male) identified with a mean age of 35 years (range, 32–50 years). The mean time interval from gastric bypass to pancreatic resection was 42.6 months (range, 10–72 months). Indications for pancreatic operations were islet hyperplasia in two patients, chronic pancreatitis in two, and serous cystadenoma in one. Two patients underwent duodenal-preserving pancreatic head resection (Beger procedure) and three underwent distal pancreatectomy and splenectomy. Mean length of hospital stay was 11.4 days (range, 5–22 days). Two patients had extended hospital stay as a result of gastrointestinal ileus. There was no other operative morbidity or mortality. Mean length of patient follow up was 9.8 months (range, 1–17 months). Specific operative techniques used in pancreatic head resection were duodenal preservation, pancreatic drainage with an omega loop constructed from a mid-Roux limb, and excluded stomach gastrostomy. Techniques used in pancreatic tail and body resection were splenectomy discontinuous from pancreatectomy, division of the splenic vein and artery at the pancreatic neck early in surgery, retrograde dissection of the pancreas body and tail, and dissection of the body and tail posterior to the Roux limb leaving the Roux limb intact. Pancreatic resection after Roux-en-Y gastric bypass is safe and effective when using prescribed operative principles that minimize disruption of the foregut reconstruction and adds protection to the gastric remnant with a gastrostomy for decompression and access for enteral alimentation when necessary.
Breast MR for the Evaluation of Occult Nipple Discharge
Authors: Mortellaro Vincent E. , Marshall Julia , Harms Steven E. , Hochwald Steven N. , Copeland Edward M. , Grobmyer Stephen R.
Published: June 2020

Pathologic nipple discharge often presents a diagnostic and therapeutic dilemma for clinicians. We present two patients with pathologic nipple discharge in whom breast MR facilitated preoperative identification of and management of otherwise occult index lesions. Breast MR should be considered in the toolbox for evaluation of occult nipple discharge when other available strategies have failed to demonstrate an underlying etiology for the pathologic discharge. The use of breast MR in this setting may permit directed evaluation and management of potentially malignant lesions.
Subcutaneous Linea Alba Fasciotomy: A Less Morbid Treatment for Abdominal Compartment Syndrome
Authors: Cheatham Michael L. , Fowler Jessica , Pappas Peter
Published: June 2020

Abdominal compartment syndrome is a cause of significant morbidity and mortality among surgical patients. It has traditionally been treated by abdominal decompression with the associated risks of chronic incisional hernia and enteroatmospheric fistula. Subcutaneous linea alba fasciotomy has recently been described as a new surgical technique for the treatment of abdominal compartment syndrome secondary to acute pancreatitis. This technique reduces intra-abdominal pressure and restores organ function while maintaining the skin and peritoneum intact for visceral protection. We describe the application of subcutaneous linea alba fasciotomy as a safe and effective alternative for the surgical management of abdominal compartment syndrome in a traumatically injured patient refractory to comprehensive medical interventions.
Prevalence of Sleep Apnea in Morbidly Obese Patients who Presented for Weight Loss Surgery Evaluation: More Evidence for Routine Screening for Obstructive Sleep Apnea before Weight Loss Surgery
Authors: Lopez Peter P. , Stefan Bianca , Schulman Carl I. , Byers Patricia M.
Published: June 2020

The incidence of obstructive sleep apnea has been underestimated in morbidly obese patients who present for evaluation for weight loss surgery. This retrospective study shows that the incidence of obstructive sleep apnea in this patient population is greater than 70 per cent and increases in incidence as the body mass index increases. Obstructive sleep apnea (OSA) is a common comorbidity in obese patients who present for evaluation for gastric bypass surgery. The incidence of sleep apnea in obese patients has been reported to be as high as 40 per cent. A retrospective review of our prospectively collected database was performed. All patients being evaluated for weight loss surgery for obesity were screened preoperatively for OSA using a sleep study. The overall incidence of sleep apnea in our patients was 78 per cent (227 of 290). All 227 were diagnosed by formal sleep study. There were 63 (22%) males and 227 (78%) females. The mean age was 43 years (range, 17–75 years). The mean body mass index (BMI) was 52 kg/m2 (range, 31–94 kg/m2). The prevalence of OSA in the severely obese group (BMI 35–39.9 kg/m2) was 71 per cent. For the morbidly obese group (BMI 40–40.9 kg/m2), the prevalence was 74 per cent and for the superobese group (BMI 50–59.9 kg/m2) 77 per cent. Those with a BMI 60 kg/m2 or greater, the prevalence of OSA rose to 95 per cent. The incidence of sleep apnea in patients presenting for weight loss surgery was greater than 70 per cent in our study. Patients presenting for weight loss surgery should undergo a formal sleep study to diagnose OSA before bariatric surgery.
Insulin Requirements in the Intensive Care Unit in Response to Infection
Authors: Maloney Nell , Britt Rebecca C. , Rushing Gregory D. , Reed Scott F. , Cole Fredric C. , Collins Jay N. , Weireter Leonard J. , Britt L.D.
Published: June 2020

Infectious complications in the intensive care unit (ICU) are classically identified when an elevated temperature triggers obtaining cultures. Elevated temperature, however, is a nonspecific marker of infection and may occur well into the course of the infection. The goal of this study was to evaluate whether escalating insulin demands may serve as an earlier marker for infection. A retrospective review of a prospective database from a trauma ICU over a 6-month period was done for all patients who developed infection while in the ICU. All patients in the ICU are placed at admission on an intensive insulin protocol with target blood glucose levels between 80 and 110 mg/dL. Data were collected on infection, insulin needs, blood glucose levels, temperature, white blood cell count, and antibiotic use. Twenty-four infections were identified, with 16 pneumonias, four bloodstream infections, and four urinary tract infections. Twelve of the 24 patients had increasing insulin needs in the 3 days preceding their infection diagnosis, with nine of the 12 requiring continued escalation of insulin needs from preinfection Day 3 to 2 to 1 (D3, D2, D1). In five of the 12 patients, the escalation of insulin dose preceded the elevated temperature, and in three of the 12 patients, the escalation preceded elevation of the white blood cell count above 12. For all 24 patients, the average insulin dose increased steadily, from 1.8 U/hr on D3 preinfection to 2.5 U/hr D2 and 3.1 U/hr D1. Infection does seem to be preceded by escalating insulin demands in many patients. A prospective study to evaluate the value of increased insulin demand as a marker for developing infection is warranted.
Taser and Taser Associated Injuries: A Case Series
Authors: Mangus Barry E. , Shen Luke Y. , Helmer Stephen D. , Maher Janae , Smith R. Stephen
Published: June 2020

Taser devices were introduced in 1974 and are increasingly used by law enforcement agencies. Taser use theoretically reduces the risk of injury and death by decreasing the use of lethal force. We report a spectrum of injuries sustained by four patients subdued with Taser devices. Injuries identified in our review included: 1) a basilar skull fracture, right subarachnoid hemorrhage, and left-sided epidural hemorrhage necessitating craniotomy; 2) a concussion, facial laceration, comminuted nasal fracture, and orbital floor fracture; 3) penetration of the outer table and cortex of the cranium by a Taser probe with seizure-like activity reported by the officer when the Taser was activated; and 4) a forehead hematoma and laceration. The Taser operator's manual states that these devices are designed to incapacitate a target from a safe distance without causing death or permanent injury. However, individuals may be exposed to the potential for significant injury. These devices represent a new mechanism for potential injury. Trauma surgeons and law enforcement agencies should be aware of the potential danger of significant head injuries as a result of loss of neuromuscular control.
How We Die: The Impact of Nonneurologic Organ Dysfunction after Severe Traumatic Brain Injury
Authors: Kemp Clinton D. , Johnson J. Chad , Riordan William P. , Cotton Bryan A.
Published: June 2020

Although nonneurologic organ dysfunction (NNOD) has been shown to significantly affect mortality in subarachnoid hemorrhage, the contribution of NNOD to mortality after severe traumatic brain injury (TBI) has yet to be defined. We hypothesized that NNOD has a significant impact on mortality after severe TBI. The trauma registry was queried for all patients admitted between January 2004 and December 2004 who died during their initial hospitalization after severe TBI (head Abbreviated Injury Score 3 or greater). Cause of death and contributing factors to mortality were determined by an attending trauma surgeon from the medical record. The data were analyzed using both Fisher's exact and Wilcoxon rank sum. One hundred thirty-five patients met inclusion criteria. Sixty-seven per cent were males, 83 per cent were white, and the mean age was 38.5 years. Mean length of stay was 2.9 days. Fifty-four patients (40%) had isolated TBI (chest Abbreviated Injury Score = 0, abdominal Abbreviated Injury Score = 0). Of the 81 deaths attributed to a single cause, 48 (60%) patients died from nonsurvivable TBI or brain death, whereas 33 (40%) died of a nonneurologic cause. Cardiovascular and respiratory dysfunction (excluding pneumonia) contributed to mortality in 51.1 per cent and 34.1 per cent of patients, respectively. NNOD contributes to approximately two-thirds of all deaths after severe TBI. These complications occur early and are seen even among those with isolated head injuries. These findings demonstrate the impact of the extracranial manifestations of severe TBI on overall mortality and highlight potential areas for future intervention and research.
Thromboembolic Prophylaxis in Blunt Traumatic Intracranial Hemorrhage: A Retrospective Review
Authors: Depew Aron J. , Hu Charles K. , Nguyen Andre C. , Driessen Natalie
Published: June 2020

There are few data in the literature on venous thromboembolic (VTE) prophylaxis for the traumatic population with intracranial hemorrhage (ICH). We reviewed our institutional experience and compared the incidence of deep vein thrombosis and pulmonary embolism in patients with ICH receiving either early prophylaxis (<72 hours from admission) or late prophylaxis (>72 hours from admission), and the respective incidences in progression of intracranial hemorrhage. We identified 124 patients for this study. There were 29 patients (23%) who received early (<72 hours) pharmacological VTE prophylaxis and 53 patients (43%) received late (>72 hours) prophylaxis. In the study, 42 patients had intermittent pneumatic compression devices and received no pharmacological VTE prophylaxis. Among those with pharmacological VTE prophylaxis, 10 patients (8%) developed VTE (9 deep vein thrombosis and 1 pulmonary embolism). Three patients with pharmacological VTE prophylaxis developed ICH progression, with one being clinically significant. Our institutional review demonstrated that it seems safe to initiate early pharmacological VTE prophylaxis in blunt head trauma with stable ICH. Nevertheless, further prospective randomized studies are needed to fully elucidate the safety and efficacy in the timing of prophylaxis for blunt head trauma with ICH.
Can Computed Tomography Scan be Performed Effectively in the Diagnosis of Acute Appendicitis without the Added Morbidity of Rectal Contrast?
Authors: Dearing Daniel D. , Recabaren Jamesa , Alexander Magdi
Published: June 2020

The highest degrees of accuracy have been demonstrated for CT scans using rectal contrast in diagnosing appendicitis. However, the administration of rectal contrast is associated with patient discomfort and rarely, rectosigmoid perforation (0.04%). Additionally, the commonly accepted negative appendectomy rate is around 16 per cent. We performed a retrospective review of radiology, operative, and pathology reports of consecutive patients undergoing appendectomy or CT examination for appendicitis during 2006. CT scans were performed without rectal contrast. The accuracy of each type of inpatient CT examination and negative appendectomy rates were determined. Two hundred and thirty-eight patients underwent appendectomy. One hundred and thirty-four appendectomy patients (56%) received a preoperative CT scan. The negative appendectomy rates were 6.3 per cent overall, 8.7 per cent without CT examination and 4.5 per cent with CT (P = 0.3). Two hundred and forty-five inpatient CT scans were performed for suspected appendicitis with a sensitivity of 90 per cent, specificity of 98 per cent, accuracy of 94 per cent, positive predictive value of 98 per cent, and negative predictive value of 91 per cent. CT scanning without rectal contrast is effective for the diagnosis of acute appendicitis making rectal contrast, with its attendant morbidity, unnecessary. The previously acceptable published negative appendectomy rate is higher than that found in current surgical practice likely due to preoperative CT scanning.
The Impact of Hospital Volume on the Number of Nodes Retrieved and Outcome in Colorectal Cancer
Authors: Truong Caitlyn , Wong Jan H. , Lum Sharon S. , Morgan John W. , Roy-Chowdhury Sharmila
Published: June 2020

We sought to examine the impact of hospital surgical volume on the number of nodes harvested and survival in colorectal cancer (CRC). Between January 1994 and December 2004, a total of 8567 patients with T1, 2, 3, and 4 primary tumors and N0, N1, or N2 disease were studied. Hospitals were stratified into very low volume (VLV) (<33 cases/year), low volume (LV) (33–56 cases/year), and medium volume (MV) (57–84 cases/year). Surgery for CRC was performed most commonly at VLV hospitals: 3488 (40.7%) VLV centers versus 2359 (27.5%) LV centers versus 2720 (31.7%) MV centers. The mean number of nodes retrieved for VLV centers was 8.6, for LV centers 9.4, and MV centers 10.2 (P < 0.0002). Actuarial 5-year survival for VLV centers was 71.4 per cent, for LV centers 75.6 per cent, and for MV 77.0 per cent (P < 0.00001). By Cox proportional hazards analysis, hospital volumes (P < 0.0011) and the number of lymph nodes harvested (P < 0.0034) remain significant predictors of disease specific survival. The number of nodes retrieved is impacted by hospital volumes. Hospital volumes impact survival in CRC. These findings cannot be attributed solely to improved staging due to increased node retrieval in VLV, LV, and MV hospitals.
Remission of Diabetes after Laparoscopic Gastric Bypass
Authors: Smith Brian R. , Hinojosa Marcelo W. , Reavis Kevin M. , Nguyen Ninh T.
Published: June 2020

Diabetes is a well-recognized and treatable risk factor for cardiac disease, and one of many comorbidities associated with obesity. The aim of this study was to evaluate the clinical outcome of a cohort of morbidly obese patients with documented diabetes who underwent laparoscopic Roux-en-Y gastric bypass. Fifty-nine patients with sufficient follow-up were included in the study. Mean preoperative duration of diabetes was 68 months. At 1 month postoperatively, mean excess body weight loss was 17 per cent with 29 patients (49%) showing improvement and 21 patients (36%) having remission of their disease. Mean excess body weight loss was 67 per cent at 12 months postoperatively with 25 patients (42%) showing improvement and 34 patients (58%) having remission of diabetes. Mean preoperative fasting blood glucose level decreased from 152 g/dL preoperatively to 100 g/dL at 12 months (P = 0.02), whereas glycosylated hemoglobin decreased from 7.9 per cent to 5.7 per cent, respectively (P < 0.01). Patients with remission of diabetes had a shorter length of condition compared with patients with only improvement (43 vs 103 months, P < 0.01). Weight loss associated with laparoscopic gastric bypass significantly improves diabetes control and results in discontinuation or marked reduction of antidiabetic medications in the majority of patients. Improvement in glucose control occurs as early as 1 month postoperatively.
Successful Management of Occult Pneumothorax without Tube Thoracostomy despite Positive Pressure Ventilation
Authors: Barrios Cristobal , Tran Tuan , Malinoski Darren , Lekawa Michael , Dolich Matthew , Lush Stephanie , Hoyt David , Cinat Marianne E.
Published: June 2020

The objective of this study was to determine whether tube thoracostomy can be safely avoided in a subset of patients with blunt occult pneumothorax. A retrospective review was performed. Management without tube thoracostomy was attempted for 59 occult pneumothoraces and was successful in 51 (86%). Observation was successful in 16 of 20 occult pneumothoraces (80%) exposed to positive pressure ventilation within 72 hours of admission. Eight delayed tube thoracostomies were required an average of 19.7 hours post admission. Patients who failed observant management had more significant physiologic derangement on admission (revised trauma score 6.96 vs 7.66, P = 0.04), were more likely to have significant multisystem trauma (88% vs 37%, P = 0.007), but were not more likely to require positive pressure ventilation (PPV) (50% vs 31%, P = 0.31). This study demonstrates that a subset of patients with blunt occult pneumothorax requiring positive pressure ventilation may be safely managed without tube thoracostomy.
Laparoscopic Gastric Bypass at a Large Academic Medical Center: Lessons Learned from the First 1000 Cases
Authors: Tejirian Talar , Jensen Candice , Lewis Catherine , Dutson Erik , Mehran Amir
Published: June 2020

Bariatric surgery is an effective and durable treatment for morbid obesity in properly selected patients. Surgical outcomes and patient management methods should routinely be reviewed to improve patient care and maintain long-term effectiveness of the bariatric operation. Over a 5-year period, 1096 laparoscopic Roux-en-Y gastric bypass operations were performed at our institution. A comprehensive prospective database was maintained, which included data for comorbidities, operative techniques, perioperative management, complications, and follow up. Many practice patterns such as the omission of routine preoperative sleep apnea testing and biliary ultrasounds remained constant and were validated by the outcomes measured. Several changes, however, were implemented based on outcomes analyses, including antecolic placement of the roux limb, a pars flaccida approach to the creation of the gastric pouch, longer alimentary limbs in superobese patients, and a selective approach to postoperative upper gastrointestinal imaging. Postoperative weight regain and inability to maintain long-term follow up in a significant per cent of patients were two identified and ongoing problems. Maintenance of a bariatric patient database is essential with its routine review resulting in changes to practice patterns and operative techniques. An effective method for long-term patient follow up remains elusive and may contribute to postoperative weight regain in some patients.
Changing Concepts in the Pathogenesis, Evaluation, and Management of Solitary Rectal Ulcer Syndrome
Authors: Ortega AdriÁN E. , Klipfel Nancy , Kelso Rebecca , Petrone Patrizio , RomÁN Ivan , DÍAz Alberto , Ávalos Brenda , Kaufman Howards
Published: June 2020

The purpose of this study was to assess the impact of new technology on both the understanding of the underlying pathophysiology and treatment of solitary rectal ulcer syndrome (SRUS). This study is a retrospective review of patients with a histologic diagnosis of SRUS (1993 to 2007) complimented with a prospective database of those patients studied with defecography and dynamic pelvic MRI. Thirty patients were available for evaluation. A polyp or mass was present in 74 per cent. Ulcers were found in only 23 per cent. All 12 patients undergoing defecography demonstrated rectorectal intussusception. Dynamic MRI of the pelvis revealed pronounced anorectal redundancy and lack of mesorectosacral fixation with mild to severe pelvic floor descent in all four patients studied. Fiber with or without stool softeners was the initial treatment in all patients with resolution of symptoms in 65 per cent. One patient with refractory symptoms underwent a stapled transanal rectal resection with complete resolution of symptoms. Occult rectorectal intussusception appears to be the operant anatomic pathology in SRUS. Anorectal redundancy with lack of mesorectosacral fixation may contribute to the process. All patients should be studied with defecography and dynamic MRI. Stapled transanal rectal resection may offer a promising surgical option.
Regional Differences in the Use of Sentinel Lymph Node Biopsy for Melanoma: A Potential Quality Measure
Authors: Lane Karen , Kempf Ashley , Magno Cheryl , Lane John , Butler John , Hsiang David , Greenfield Sheldon , Jakowatz James
Published: June 2020

Sentinel lymph node biopsy (SLNB) provides accurate nodal staging in patients with melanoma. However, its prevalence across geographic regions is unknown. Our aim was to determine if SLNB for melanoma has been widely adopted throughout the United States. All patients in the Surveillance, Epidemiology and End Results (SEER) cancer registry for 2004 with melanoma were evaluated. Data were collected for demographics, depth of melanoma, and type of nodal evaluation (regional lymph node dissection vs SLNB). Registry sites were categorized into West, Midwest, Northeast, and Southeast. χ2 analysis was performed to identify regional differences in receipt of SLNB. Overall, the West region (n = 2352) had a higher use of SLNB compared with the Midwest (n = 497), Northeast (n = 630), and Southeast (n = 268) regions (82.1% vs 77.9%, 65.4%, and 60.1%, respectively; P < 0.001). Intermediate-thickness (1 to 4 mm) melanomas had differences in SLNB use between the West and Midwest (83.6% and 81.4%) versus the Northeast and Southeast (66.3% and 60.2%) (P < 0.05). This population-based analysis shows low use of SLNB for melanoma in some U.S. regions. Further studies need to address the reasons for these differences and target ways to improve rates. Results suggest that SLNB may be considered as a potential quality measure.
Operative Strategy Can Reduce the Incidence of Major Bile Duct Injury in Laparoscopic Cholecystectomy
Authors: Yegiyants Sara , Collins J. Craig
Published: June 2020

Major bile duct injury (BDI) rates remain in the range of 0.3 to 0.5 per cent for laparoscopic cholecystectomy (LC). The dominant surgical technique worldwide continues to be the “infundibular” technique of dissection that was popularized in the early 1990s. Proponents of the “critical view of safety” (CV) technique have suggested that most of these injuries are avoidable. The objective of our study was to determine whether routine use of the CV technique reduced the observed/expected single-institution rate of major BDI over a 5-year period in a teaching hospital. All patients (n = 3042) who underwent LC for any indication at one institution over a 60-month period were identified by database search. Major BDI was identified by Common Procedural Terminology codes indicating operative repair and confirmed by review of medical records. One patient sustained a transection–excision of the common duct requiring hepaticoduodenostomy. Based on published data, the observed BDI rate was one in nine to one in 15 of the expected rate. This represents an order-of-magnitude improvement in the safety of LC at a single institution where the majority of cases were performed by residents. We suggest that the “critical view” technique should be widely adopted.
Tissue Oxygen Saturation Predicts the Need for Early Blood Transfusion in Trauma Patients
Authors: Smith Jennifer , Bricker Scott , Putnam Brant
Published: June 2020

Near-infrared spectroscopy (NIRS) has been used to measure regional tissue oxygen saturation (StO2) in skeletal muscle as an indicator of perfusion in trauma patients. In an effort to prospectively examine the usefulness of StO2 in identifying trauma patients in hemorrhagic shock, we evaluated the need for blood transfusion within 24 hours of injury as a marker of significant hemorrhage. A 6-month prospective, observational study was conducted at a university-affiliated, urban Level I trauma center using a convenience sample of 26 trauma patients thought to be at high risk for hemorrhagic shock. Baseline demographic data, vital signs, laboratory values, and amounts of fluid and blood products administered were collected. NIRS-derived StO2 values were measured for 1 hour after arrival to the trauma bay and the minimum value noted. A minimum StO2 less than 70 per cent correlated with the need for blood transfusion with a sensitivity of 88 per cent and a specificity of 78 per cent. The positive predictive value was 64 per cent and the negative predictive value was 93 per cent. The need for blood transfusion within 24 hours of arrival was not predicted by hypotension, tachycardia, arterial lactate, base deficit, or hemoglobin. StO2 may represent an important screening tool for identifying trauma patients who require blood transfusion or other limited medical resources.
Treatment of Appendiceal Adenocarcinoma in the United States: Penetration and Outcomes of Current Guidelines
Authors: Walters K. Christian , Paton B. Lauren , Schmelzer Thomas S. , Gersin Keith S. , Iannitti David A. , Kercher Kent W. , Heniford B. Todd
Published: June 2020

Current treatment guidelines for appendiceal adenocarcinoma specify that right hemicolectomy should be performed. This study evaluates appendiceal cancer outcomes in the United States and treatment guideline compliance. Data for patients diagnosed with appendiceal adenocarcinoma in the Surveillance, Epidemiology, and End Results database (1988 to 2003) were analyzed. The 2511 patients with appendiceal adenocarcinoma had an average age of 59.3 years, average tumor size of 4.05 cm, and 5-year survival rate of 57 per cent. The 5-year survival rate by stage was statistically different (P < 0.001): Stage 0, 95.7 per cent; Stage I, 88 per cent; Stage II, 75.2 per cent; Stage III, 37.1 per cent; and Stage IV, 25.6 per cent. Appendectomy was performed in 33.4 per cent, which does not follow the current guidelines. In this group, 5-year survival was significantly less for patients with Stage III and IV disease (48% vs 38.2%, P = 0.03; 46% vs 26.4%, P = 0.04, respectively). Patients with Stage I and II disease had similar 5-year survival for appendectomy and colectomy (90.2% vs 90.1%, P = 0.7; 78.3% vs 76%, P = 0.6, respectively). One-third of patients with adenocarcinoma did not undergo current surgical guideline therapy. However, it appears hemicolectomy only improved survival for patients with later-stage disease. The current data raise the question of whether Stage I and II appendiceal cancer can be adequately treated with simple appendectomy.
Current Evidence Based Guidelines for Factor VIIa Use in Trauma: The Good, the Bad, and the Ugly
Authors: Duchesne Juan C. , Mathew Kavitha A. , Marr Alan B. , Pinsky Michael R. , Barbeau James M. , Mcswain Norman E.
Published: June 2020

Recombinant factor VII (rFVIIa) has arisen as an option for the control of life-threatening traumatic bleeding unresponsive to other means. The timing of administration, dosage, mortality, units of blood transfusion saved, risk of thrombotic events, and risk/benefits ratio are presently poorly defined. A Medline search from 1995 through March 2008 was conducted. All English language articles containing the terms “trauma” and “factor VII” or its variants were retrieved. Letters to the editor, animal studies, and general reviews were excluded. A total of 19 articles met inclusion criteria. These articles were then reviewed and stratified into three classes of evidence according to the quality assessment instrument developed by the Brain and Trauma Foundation. Levels of recommendation were developed. A total of 118 articles were identified. Only one Class I study was identified. This study demonstrated that three doses of rFVIIa given in blunt traumatic hemorrhage yielded a significant reduction of 2.6 of red blood cells used. These findings were not statistically significant for penetrating trauma patients. There was no reduction in mortality and no increase in thromboembolic events. Four Class II studies were identified; three showed a significant decrease of blood product usage and one demonstrated significant reductions in 24-hour and 30 day death from hemorrhage in patients receiving rFVIIa. The remaining 14 studies were Class III reviews of databases, registries, case series, and case reports. No identified study specifically addressed the cost/benefit analysis of rFVIIa usage in trauma hemorrhage. Utility of rFVIIa in trauma-associated hemorrhage remains controversial. There is Level I supporting the use of rFVIIa for blunt trauma patients only. There is no Class I evidence supporting decreased mortality or differences in thromboembolic events. Minimal effective dosing regimens and cost/benefit analyses have not yet been examined.