bluuebunny/crossref_metadata_2025 huggingface dataset:
Nutritional Status Does Not Correlate with Stump Complications in Two-stage Lower Extremity Amputations
Authors: Keeley Jessica , Kaji Amy , Kim Dennis , Plurad David , Putnam Brant , Neville Angela
Published: June 2020

Unsalvageable foot infections require a two-staged amputation: an initial guillotine below-knee amputation (BKA) followed by formalization. No literature exists regarding the optimal timing to formalization, and the role of nutrition on outcomes remains unclear. This study was conducted to evaluate whether timing to formalization or nutritional markers correlate with stump complications. A retrospective review of all guillotine BKAs done at our county-funded, academic medical center between 2008 and 2013 was performed. Comorbidities, albumin, prealbumin, glycated hemoglobin, days to formalization, and postoperative complications were recorded. Primary outcome was surgical site infection or need for reoperation of the formalized stump within 30 days. One hundred and twenty-eight guillotine BKAs and subsequent formalizations were performed. Twenty-two (17.2%) patients developed surgical site infections and six (4.9%) required reoperation. Patients formalized within 14 days were as likely to develop stump complications as those formalized later (odds ratio 0.7, 0.3–1.8, P = 0.5). When comparing patients who developed stump complications to those who did not, there was no difference in preoperative albumin (2.6 ± 0.7 vs 2.4 ± 0.7, P = 0.3), prealbumin, (14.4 ± 6.2 vs 15.2 ± 5.5, P = 0.5), or glycated hemoglobin (8.8 ± 2.9 vs 9.0 ± 2.5, P = 0.7). Neither timing of formalization nor nutritional parameters predicted wound complications.
Initial Results of Multigene Panel Testing for Hereditary Breast and Ovarian Cancer and Lynch Syndrome
Authors: Howarth Dt R. , Lum Sharon S. , Esquivel Pamela , Garberoglio Carlos A. , Senthil Maheswari , Solomon Naveenraj L.
Published: June 2020

Multigene panel testing for hereditary cancer risk has recently become commercially available; however, the impact of its use on patient care is undefined. We sought to evaluate results from implementation of panel testing in a multidisciplinary cancer center. We performed a retrospective review of consecutive patients undergoing genetic testing after initiating use of multigene panel testing at Loma Linda University Medical Center. From February 13 to August 25, 2014, 92 patients were referred for genetic testing based on National Comprehensive Cancer Network guidelines. Testing was completed in 90 patients. Overall, nine (10%) pathogenic mutations were identified: five BRCA1/2, and four in non-BRCA loci. Single-site testing identified one BRCA1 and one BRCA2 mutation. The remaining mutations were identified by use of panel testing for hereditary breast and ovarian cancer. There were 40 variants of uncertain significance identified in 34 patients. The use of panel testing more than doubled the identification rate of clinically significant pathogenic mutations that would have been missed with BRCA testing alone. The large number of variants of uncertain significance identified will require long-term follow-up for potential reclassification. Multigene panel testing provides additional information that may improve patient outcomes.
Epidural Analgesia after Rib Fractures
Authors: Zaw Andrea A. , Murry Jason , Hoang David , Chen Kevin , Louy Charles , Bloom Matthew B. , Melo Nicolas , Alban Rodrigo F. , Margulies Daniel R. , Ley Eric J.
Published: June 2020

Pain associated with rib fractures impairs respiratory function and increases pulmonary morbidity. The purpose of this study was to determine how epidural catheters alter mortality and complications in trauma patients. We performed a retrospective study involving adult blunt trauma patients with moderate-to-severe injuries from January 1, 2004 to December 31, 2013. During the 10-year period, 526 patients met the inclusion criteria; 43/526 (8%) patients had a catheter placed. Mean age of patients with epidural catheter (CATH) was higher compared with patients without epidural catheter (NOCATH) (54 vs 48 years, P = 0.021), Injury Severity Score was similar (26 CATH vs 27 NOCATH, P = 0.84), and CATH had higher mean rib fractures (7.4 vs 4.1, P < 0.001). Mortality was lower in CATH (0% vs 13%, P = 0.006). Deep vein thrombosis (DVT) rate was higher in CATH (12% vs. 5%, P = 0.036). After regression analysis, we found catheter placement to be a predictor for DVT (adjusted odds ratios 2.80, P = 0.036). Our center noted increased use of epidural catheters in patients who present with moderate-to-severe injuries. Patients with catheters were older and had a mean of 7.4 ribs fractured. The epidural cohort had longer hospital LOS and decreased mortality. In contrast to other studies, DVT rates were increased in patients who received epidural catheters.
Regional Quality Groups Enhance Effectiveness of Vascular Quality Initiative®
Authors: Dunn Joie , Weaver Fred A. , Woo Karen
Published: June 2020

The Vascular Quality Initiative (VQI)® is a national collaborative of regional quality groups that collect and analyze data to improve vascular health care. The Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe) is the regional quality group for southern California. Initial quality initiatives chosen by the So Cal VOICe are preoperative and discharge antiplatelet and statin therapy and vascular access guidance during percutaneous endovascular procedures. The objective of this study is to examine the influence of the regional quality group structure on the effectiveness of the So Cal VOICe. Data are entered by each institution into a cloud-based data collection and reporting system. So Cal VOICe data from January 2011 to July 2014 was analyzed in 6-month intervals. Preoperative statin and antiplatelet use increased from 58.87 to 71.81 per cent ( P = 0.0082) and 60.8 to 78.38 per cent ( P < 0.0001), respectively. Discharge statin and antiplatelet use increased from 69.09 to 80.37 per cent ( P = 0.0037) and 80.47 to 88.11 per cent ( P = 0.0148), respectively. Vascular access guidance improved from 32.89 to 76.23 per cent ( P < 0.0001). Our results demonstrate the unique regional quality group structure of the VQI® improves compliance with selected process measures in the So Cal VOICe. Continued data collection will determine the impact of these process improvements on long-term patient outcomes.
Timing and Pattern of Recurrence after Gastrectomy for Adenocarcinoma
Authors: Alnoor Mohammad , Boys Joshua A. , Worrell Stephanie G. , Oh Daniel S. , Hagen Jeffrey A. , Demeester Steven R.
Published: June 2020

Gastric adenocarcinoma has a high recurrence rate. The goal of this study was to determine the timing and pattern of recurrence after gastrectomy. A retrospective review was performed of patients with gastric adenocarcinoma having curative partial or total gastrectomy with R0/D2 lymph node resection from 1999 to 2013. Follow-up included CT scans of the chest, abdomen, and pelvis at 3-month intervals for the first three years, at 6-month intervals for the next two years, and annually thereafter. There were 62 patients, 38 males and 24 females, with a median age of 65 years. Median follow-up was 29 months and recurrence was identified in 21 per cent of patients. Median time to recurrence was 12 months and 92 per cent of recurrences occurred within two years. The last recurrence was identified at 34 months. Abdominal CT scan identified all patients with recurrence, although some patients had disease elsewhere in addition to the abdominal disease. There were no extra-abdominal isolated recurrences. In conclusion, recurrence after complete resection for gastric adenocarcinoma typically occurs within the first two years, and can be found by abdominal CT scan. Close cancer follow-up appears unnecessary after three years because all recurrences were identified within 34 months of resection.
Short-term Outcomes of Laparoscopic versus Open Formal Anatomical Hepatectomy: A Case Matched Control Study
Authors: Lau Briana , Franken Cara , Lee David , Putchakayla Krishna , DiFronzo L. Andrew
Published: June 2020

Variability in extent and complexity of hepatic resection complicates prior laparoscopic (LH) and open (OH) hepatectomy comparisons. This study compares the 30-day outcomes of formal anatomical LH and OH by matching patients by location and extent of resection. A retrospective review was conducted for patients undergoing formal anatomical hepatectomies from January 2008 to November 2014. Of 580 liver procedures, 78 formal OH and 47 LH meeting criteria were identified. A total of 26 pairs were strictly matched based on resection extent and location, underlying pathology, age, and gender. The primary outcome was complication rate. Secondary outcomes were intraoperative blood loss estimated blood loss, procedure time, transfusion, and hospital stay. The groups were similar with regard to patient demographics. Right or left hepatectomy were most common (14 pairs, 53.8%). On average, 2.8 liver segments were resected. Nine LH cases (36%) were converted to open. Using intention to treat analysis, there were no significant differences in overall complications (46% vs 54%, P = 0.274) or major (Clavien ≥ 3) complications (19% vs 8%, P = 0.223), mean estimated blood loss (386 vs 556 mL, P = 0.216), procedure time (269 vs 255 minutes, P = 0.406, or hospital stay (6.0 vs 5.6 days, P = 0.643). When appropriately matched, there were equivalent short-term outcomes between formal LH and OH.
Anal Adenocarcinoma: Outcomes in an Uncommon Malignancy
Authors: Bertelson Noelle , Blumetti Jennifer , Cintron Jose , Harrison Jacquelyn , Chaudhry Vivek , Abcarian Herand
Published: June 2020

Adenocarcinoma is an uncommon malignancy of the anal canal. Although it is recognized as an aggressive disease, optimal management and long-term outcomes are not well established. Patients diagnosed with anal adenocarcinoma were identified from a cancer database. Their charts were reviewed for patient and disease characteristics, management, and outcomes. Eighteen patient charts from 1997 to 2012 were reviewed. Nine patients presented with stage II disease, five with stage III, three with stage IV, and one was inadequately staged before chemoradiation. One patient refused treatment, one patient went straight to abdominoperineal resection, 13 patients underwent initial chemoradiation therapy, and three underwent palliative chemotherapy. Of the 13 patients who received neoadjuvant therapy, eight underwent subsequent radical resection; three progressed during neoadjuvant and became unresectable, one had complete pathologic response and was observed, and one did not complete neoadjuvant and was lost to follow-up. Two patients with stage II disease were disease free over eight years, and one was disease free after 26 months; four patients had persistent or recurrent local disease, and 10 developed metastatic disease. Seven patients died with disease at a median 16 months, and the other seven were alive with disease at a median follow-up of 10 months. Patients with anal adenocarcinoma present at advanced stages, and cure is rare. Although chemoradiation followed by abdominoperineal resection is the most common management strategy, the potential for curative resection and long-term disease free survival is minimal, regardless of stage at presentation.
Repair of Small and Medium Size Umbilical Hernias with the “Proceed Ventral Patch” in the Preperitoneal Position
Authors: Zarmpis Nikolaos , Wassenberg Dirk , Ambe Peter C.
Published: June 2020

Small- and medium-sized ventral hernias including umbilical hernias can be repaired using prosthetic patches placed in the peritoneum. However, bowel-associated complications secondary to intraperitoneally placed hernia patches have been reported. Herein, we report the outcome of small and medium umbilical hernia closure with prosthetic hernia patches in the preperitoneal space. Prospectively collected data of patients undergoing repair of small- and medium-sized umbilical hernias with the proceed ventral patch in a primary care hospital in Germany was retrospectively analyzed. A total of 39 cases, including 11 female and 28 male patients, were managed with prosthetic patches in the preperitoneal position. Small-sized patches were implantated in 16 cases, whereas medium-sized patches were used in 23 cases. The median duration of surgery was 40 minutes. The median length of hospital stay was four days. Four minor complications were recorded (10.3%) and the rate of recurrence was 2.6 per cent within a follow-up period of up to 30 months. Small and medium size umbilical hernias can be effectively closed with prosthetic patches placed in the preperitoneal space without risk of serious bowel associated complications.
Acute Genital Edema during Peritoneal Dialysis: A Review for Surgeons
Authors: Jorge Juaquito , Haggerty Stephen P.
Published: June 2020

Acute genital edema (AGE) is an infrequent but disruptive complication in patients on continuous ambulatory peritoneal dialysis. It is a common manifestation of dialysate leakage caused by inguinal, umbilical, femoral, or incisional hernias; peritoneal tears; leaks around the dialysis catheter; trauma; fluid overload; and malignancy. The evaluation of AGE begins with a history and physical exam. However, the physical exam in these patients is often indeterminate. Several diagnostic measures exist to evaluate and guide management of AGE occurring during continuous ambulatory peritoneal dialysis but little agreement exists on an optimum method. We have conducted a review of the literature on the evaluation and management of AGE and present a summary of the data. CT peritoneography and peritoneal scintigraphy have been used extensively to evaluate AGE although no comparative studies exist. MRI peritoneography has also been described. CT peritoneography offers more anatomical detail but may not be as sensitive as peritoneal scintigraphy in detecting a peritoneal fluid leak as the cause for AGE. CT is also more costly and subjects the patient to more radiation. MRI is a noncontrast study without radiation risk, but has not been studied to the same degree. If testing is equivocal or bilateral hernias are suspected, diagnostic laparoscopy is helpful and can be combined with hernia repair. Whether the etiology is a leak or tear, low-volume peritoneal dialysis (PD) or cessation of PD for two to four weeks will allow closure. However, hernias almost always require operative repair with mesh usually without disrupting PD.
The Influence of Resected Gastric Weight upon Weight Loss after Sleeve Gastrectomy
Authors: Rosas Ulysses , Hines Harrison , Rogan Daniel , Rivas Homero , Morton John
Published: June 2020

Bariatric surgery is an effective and enduring treatment for obesity. Sleeve gastrectomy (SG) has emerged as an increasingly prevalent surgical intervention. Further investigation is required to determine optimal standardization of SG. Data were collected prospectively for 64 patients who underwent a laparoscopic vertical SG between December 2010 and February 2013 at a single academic institution. Demographic, intraoperative, and postoperative (postop) data were collected for all patients including weighing each resected stomach. The total resected gastric weight varied widely. Preoperatively, patients in the upper tercile for resected gastric weight were more likely to be male (lower 10%, middle 23%, upper 52%, P = 0.006) and had greater initial weights (lower 255.9%, middle 245.1%, upper 280.0%, P = 0.019). The resected gastric weight (g) varied by tercile (mean of all, 131.24 ± 39.8; lower, 93.9 ± 10.9; middle, 127.4 ± 11.7; upper 172.7 ± 37.9, P = 0.000). Patients were followed for 1-year postop with follow-up data for 94 per cent (60/64) of participants. Per cent excess weight loss (EWL) was obtained at three, six, and 12 months postop. At 12 months, there was a trend toward increased per cent EWL in the upper tercile (lower 61.1%, middle 54.1%, upper 90.5%, P = 0.057).

In conclusion, while the amount of gastric sleeve resected can vary, this study shows that intraoperative assessment of resected sleeve weight can help evaluate adequacy of resection. Improved 12-month per cent EWL in patients with greater resected tissue demonstrate potentially improved outcomes.
Left-sided Gallbladder in the Era of Laparoscopic Cholecystectomy: A Single-center Experience
Authors: Velimezis Georgios , Vassos Nikolaos , Kapogiannatos Georgios , Koronakis Dimitrios , Salpiggidis Christos , Perrakis Evangelos , Perrakis Aristotelis
Published: June 2020

The malposition of gallbladder under the liver segment III, defined as left-sided gallbladder (LSG), is an unexpected situation for the laparoscopic surgeon. The purpose of this study is to present our experience in treating patients with cholecystitis and LSG discovered incidentally during laparoscopic surgical procedure. Between 1993 and 2009, 5569 patients underwent laparoscopic cholecystectomy in our surgical department. Their records were reviewed and seven patients revealed having LSG (0.12%). Analysis parameters included demographic data, diagnostic methods, mode of surgery, and postoperative outcome. Mean follow-up was 140 months. Of the seven patients, five were women. Mean patient age was 56.7 years. All patients were referred to our department with clinical symptoms of classic cholelithiasis and the diagnosis was established in all of them during surgery. Laparoscopic cholecystectomy was successful in five patients, while in two patients, a conversion to open procedure was needed. A postoperative complication, i.e., biliary leakage was registered in one patient, which was treated successfully. Laparoscopic cholecystectomy is safe even in LSG, but the surgeon must consider the possibility for more anatomical anomalies, adjust the technique of dissection, and must not hesitate, if in doubt, to strive for conversion to open procedure to avoid serious complications.
Outcomes of 157 V-Patch™ Implants in the Repair of Umbilical, Epigastric, and Incisional Hernias
Authors: Keating Jane J. , Kennedy Gregory T. , Datta Jashodeep , Schuricht Alan
Published: June 2020

Umbilical, epigastric, and incisional hernias have traditionally been repaired using a Mayo or tensioned suture technique, with recurrence rates of approximately 50 per cent. Recent studies have shown that a tension-free repair using mesh can drastically decrease recurrence rates. Reinforced deployment prostheses are preferred because they enable retrofascial placement through a small incision, thus avoiding the potential morbidity of a larger incision and the costs associated with a laparoscopic approach. A retrospective chart review was performed of all umbilical, epigastric and incisional hernias repaired with V-Patch, a reinforced deployment prosthesis, by a single surgeon. Data analysis included patient characteristics, operative and postoperative metrics, hernia recurrence, and complication rates. Between 2009 and 2012, 157 implantations were performed in 152 patients during 156 procedures. Patient age ranged from 20 to 85 (mean 48). There were 88 females (57.9%) and 64 males (42.1%) with average body mass index of 30.6. Patch size distribution was 78 small (49.7%), 55 medium (35.0%), and 24 large (15.3%). There were 81 umbilical hernias (51.6%), 36 epigastric hernias (22.9%), 39 incisional hernias (24.8%), and 1 multiple recurrent inguinal hernia (0.6%) repaired. Follow-up time ranged from 18 months to 4.3 years. There were six hernia recurrences (3.2%). Complications included three patients (1.9%) with mesh infection, one with an enterocutaneous fistula (0.6%), and one patient with a postoperative small bowel obstruction (0.6%). Four patients required patch explantation (2.5%). The V-Patch reinforced deployment prosthesis is effective in the treatment of umbilical, epigastric, and incisional hernias, and has a low rate of complications.
Restrictive Transfusion in Geriatric Trauma Patients
Authors: Deleon Ashley N. , Uecker John M. , Stafford Susan V. , Ali Sadia , Clark Adam , Brown Carlos V. R.
Published: June 2020

To determine whether a restrictive strategy of red cell transfusion was safe in elderly trauma patients, we compared those treated with a restrictive transfusion strategy versus those who were liberally transfused. We performed a retrospective study of elderly (age ≥ 70 years) trauma patients admitted to our Level I trauma center from 2005 to 2013. Patients with a hemoglobin (Hg) < 10 g/dL after 48 hours were included. We excluded patients with an Injury Severity Score > 25 or active cardiac ischemia. Patients who were transfused for an Hg < 10 g/dL (liberal group) were compared to those who were transfused for an Hg< 7 g/dL (restrictive group). There were 382 patients included, 229 and 153 in the liberal and restrictive transfusion groups, respectively. All patients in the liberal group and 20 per cent of patients in the restrictive group received a transfusion ( P < 0.0001). Patients in the liberal group had more overall complications (52 vs 32%, P = 0.0001). On multivariate analysis, receiving a transfusion was an independent risk factor to develop a complication [odds ratio = 2.3 (1.5–3.6), P < 0.0001]. For survivors, patients in the liberal group spent more days in the hospital (nine versus seven days, P = 0.007) and intensive care unit (two versus one day, P = 0.01). There was no difference in mortality (3 vs 4%, P = 0.82). In conclusion, restrictive transfusion appears to be safe in elderly trauma patients and may be associated with decreased complications and shortened length of stay.
Pseudoangiomatous Stromal Hyperplasia on Core Needle Biopsy Does Not Require Surgical Excision
Authors: Protos Adam , Nguyen Kim T. , Caughran Jamie L. , Naski Michael , Keto Jessica L.
Published: June 2020

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon, benign localized fibrotic lesion. Historically, PASH has been difficult to differentiate from angiosarcoma. This difficulty has led to recommendations of surgical excision. We sought to identify the incidence of upgraded pathology to atypia or malignancy on surgical excisional biopsy after identification of PASH on core needle biopsy (CNB). A 5-year retrospective review at a single institution was conducted including all cases of PASH confirmed on CNB. The data set was divided into patients who underwent excisional biopsy and those followed only by imaging. Primary end points included the incidence of subsequent malignancy or high-risk pathology on histologic analysis or the presentation of suspicious imaging. Thirty-seven patients were reviewed, 19 (51.4%) underwent surgical excision and 18 (48.6%) were followed with imaging alone. A palpable mass was noted in 36.8 per cent of patients in the excisional group versus 5.6 per cent in the imaging group ( P = 0.02). The median follow-up for the excisional and imaging groups were 43 and 35 months, respectively ( P = 0.85). The 95 per cent confidence interval for the presence of malignancy was 0 to 9.4 per cent. Although further characterization of PASH is needed, our data support using CNB with follow-up imaging as a safe alternative to excisional biopsy in the absence of symptoms or other clinical factors. However, further research in this area is needed.
Seat Belt Use and its Effect on Abdominal Trauma: A National Trauma Databank Study
Authors: Nash Nick A. , Okoye Obi , Albuz Ozgur , Vogt Kelly N. , Karamanos Efstathios , Inaba Kenji , Demetriades Demetrios
Published: June 2020

We sought to use the National Trauma Databank to determine the demographics, injury distribution, associated abdominal injuries, and outcomes of those patients who are restrained versus unrestrained. All victims of motor vehicle collisions (MVCs) were identified from the National Trauma Databank and stratified into subpopulations depending on the use of seat belts. A total of 150,161 MVC victims were included in this study, 72,394 (48%) were belted. Young, male passengers were the least likely to be wearing a seat belt. Restrained victims were less likely to have severe injury as measured by Injury Severity Score and Abbreviated Injury Score. Restrained victims were also less likely to suffer solid organ injuries (9.7% vs 12%, P < 0.001), but more likely to have hollow viscous injuries (1.9% vs 1.3%, P < 0.001). The hospital and intensive care unit length of stay were significantly shorter in belted victims with adjusted mean difference: -1.36 (-1.45, -1.27) and -0.96 (-1.02, -0.90), respectively. Seat belt use was associated with a significantly lower crude mortality than unrestrained victims (1.9% vs 3.3%, P < 0.001), and after adjusting for differences in age, gender, position in vehicle, and deployment of air bags, the protective effect remained (adjusted odds ratio for mortality 0.50, 95% confidence interval 0.47, 0.54). In conclusion, MVC victims wearing seat belts have a significant reduction in the severity of injuries in all body areas, lower mortality, a shorter hospital stay, and decreased length of stay in the intensive care unit. The nature of abdominal injuries, however, was significantly different, with a higher incidence of hollow viscous injury in those wearing seat belts.
Use of Payer as a Proxy for Health Insurance Status on Admission Results in Misclassification of Insurance Status among Pediatric Trauma Patients
Authors: Carter Elizabeth A. , Waterhouse Lauren J. , Xiao Roy , Burd Randall S.
Published: June 2020

The purpose of this study was to quantify health insurance misclassification among children treated at a pediatric trauma center and to determine factors associated with misclassification. Demographic, medical, and financial information were collected for patients at our institution between 2008 and 2010. Two health insurance variables were created: true (insurance on hospital admission) and payer (source of payment). Multivariable logistic regression was used to determine which factors were independently associated with health insurance misclassification. The two values of health insurance status were abstracted from the hospital financial database, the trauma registry, and the patient medical record. Among 3630 patients, 123 (3.4%) had incorrect health insurance designation. Misclassification was highest in patients who died: 13.9 per cent among all deaths and 30.8 per cent among emergency department deaths. The adjusted odds of misclassification were 6.7 (95% confidence interval: 1.7, 26.6) among patients who died and 16.1 (95% confidence interval: 3.2, 80.77) among patients who died in the emergency department. Using payer as a proxy for health insurance results in misclassification. Approaches are needed to accurately ascertain true health insurance status when studying the impact of insurance on treatment outcomes.
An Assessment of Margins after Lumpectomy in Breast Cancer Management
Authors: Rivere Amy E. , Chiasson Katherine F. , Corsetti Ralph L. , Fuhrman George M.
Published: June 2020

We performed this study to evaluate our indications for margin re-excision (MRE) in the management of cancer patients opting for breast conservation therapy (BCT). We identified patients choosing breast conservation therapy from January 2012 to May 2014. Margins were considered negative if >2 mm, close if <2 mm, and positive if ink was detected abutting tumor. Patients with close and positive margins underwent MRE. We identified 247 patients of which 190 had negative margins and did not require MRE, 46 patients had a close margin, and 11 had a positive margin, leading to an MRE rate of 23 per cent (57 of 247). The following variables were evaluated: tumor size, stage, estrogen receptor, progesterone receptor, HER2/neu receptor, and node status. None predicted the presence of tumor in the MRE specimen ( P > 0.05). Patients with close margins had a 6.5 per cent (3 of 46), and patients with positive margins had a 36.4 per cent (4 of 11) incidence of tumor in the MRE specimens; this difference was statistically significant ( P = 0.02). The low rate of finding tumor in MRE specimens of patients with close margins after lumpectomy for breast carcinoma argues for limiting MRE to patients with positive margins (ink on tumor) only. We have adopted this approach in our institution.
Abdominal Wall Reconstruction: The Uncertainty of the Impact of Drain Duration upon Outcomes
Authors: Plymale Margaret A. , Harris Jennifer W. , Davenport Daniel L. , Smith Nicholas , Levy Salomon , Roth J. Scott
Published: June 2020

Drains are commonly used after abdominal wall reconstruction (AWR) to prevent seroma formation. Drain management is subjective, and the merits and drawbacks of drains are not well understood. After receiving Institutional Review Board approval, we queried our prospectively maintained surgical database for AWR cases from 2009 to 2012 to ascertain if the number of days postoperatively that drains are left in place impacts the incidence of surgical site complications. Number of drains, drain duration, wound complications, and interval to development of complications were recorded. Wound complications were defined as superficial cellulitis, seroma, hematoma, superficial infection, and deep infection. Among 117 AWRs, we investigated the 64 cases with Centers for Disease Control grade one wound classification. Longest drain duration varied widely (2–171 days postoperatively; mean = 22 days). Cases were divided into four groups based on duration prior to removal of all drains: ≤ 7 days (n = 18), 8 to 14 days (n = 16), 15 to 28 days (n = 18), or ≥29 days (n = 12). No significant relationship was found between incidence of seroma/hematoma and days postoperatively of last drain removal. Wound complications increased linearly with drain time. Using logistic regression to adjust for obesity (body mass index >35kg/m2), drain duration >2 weeks and operative time >220 minutes, only body mass index >35 remained an independent predictor of wound occurrence, P < 0.05. Wound complications occur frequently after AWR. Wound infections occur more commonly among patients with drains in place for more than 2 weeks. Strategies to reduce drain duration require furthermore investigation.
Evaluating the Effectiveness of the General Surgery Intern Boot Camp
Authors: Schoolfield Clint S. , Samra Navdeep , Kim Roger H. , Shi Runhua , Zhang Wayne W. , Tan Tze-Woei
Published: June 2020

The aim of our study is to evaluate the effectiveness of newly implemented general surgery intern boot camp. A 2-day didactic and skills-based intern boot camp was implemented before the start of clinical duties. Participants who did not attend all boot camp activities and had prior postgraduate training were excluded. A survey utilizing a 5-point Likert scale scoring system was used to assess the participants’ confidence to perform intern-level tasks before and after the boot camp. Subgroup analyses were performed comparing changes in confidence among graduates from home institution versus others and general surgery versus other subspecialties. In the analysis, 21 participants over two years were included. Among them, 7 were graduates from home institution (4 general surgery, 3 subspecialty) and 14 were from other institutions (6 general surgery and 8 subspecialty). There were significant increases in overall confidence levels (pre = 2.79 vs post = 3.43, P < 0.001) after the boot camp. Additionally, there were improvements for all subcategories including medical knowledge (2.65 vs 3.36, P < 0.001), technical skill (3.02 vs 3.51, P < 0.001), interpersonal skills and communication (3.04 vs 3.53, P = 0.001), and practice-based learning (2.65 vs 3.41, P = 0.001). There was an improvement in confidence level for both home institution graduates (2.89 vs 3.53, P = 0.022) and other graduates (2.74 vs 3.34, P < 0.001). Similarly, participants from general surgery (2.78 vs 3.46, P = 0.001) and other specialties (2.74 vs 3.34, P < 0.001) reported significant improvement in confidence. General surgery intern boot camp before the start of official rotation is effective in improving confidence level in performing level-appropriate tasks of the incoming new interns.
Temporary Tube Stoma versus Conventional Loop Stoma for the Protection of a Low Anastomosis in Colorectal Surgery: A Systematic Review and Meta-analysis
Authors: Zong Zhen , Zhou Taicheng , Jiang Zhipeng , Li Yingru , Yang Bin , Hou Zehui , Han Fanghai , Chen Shuang
Published: June 2020

The aim of this systematic review is to evaluate and compare the efficacy and safety of temporary tube stoma and conventional loop stoma for the protection of a low anastomosis in colorectal cancer. A systematic literature search was performed using PubMed, EMBASE, Science Citation Index, and Cochrane Central Register of Controlled Trails. Primary outcome measures were anastomotic leakage rate, the reoperation rate for anastomotic leakage, and stoma-related complications. Secondary outcome measures were operation time, length of hospital stay, time to stoma closure, and permanent stoma rate. Four studies were carried out and 642 patients (332 with temporary tube stoma and 310 with conventional loop stoma) met the inclusion criteria. The incidences of anastomotic leakage and reoperation rate were statistically similar in tube stoma and loop stoma groups. In comparison with conventional loop stoma, temporary tube stoma was associated with a significantly less stoma-related complications (odds ratio = 0.20; 95% confidence interval [CI]: 0.08–0.50), and shorter operation and hospital stay time (weighted mean difference = -47.28 minutes, 95% CI: -74.68 to -19.88; and weighted mean difference = -5.22 days, 95% CI: -10.32 to -0.13, respectively). Time to stoma closure was significantly shorter in the temporary tube stoma groups (weighted mean difference = -114.58 days, 95% CI: -148.38 to -80.77). Patients receiving temporary tube stoma had lower rates of stoma-related complications, shorter operation and hospital stay time, and stoma closure time. Tube can be easily removed without second surgery in most cases. Therefore, temporary tube stoma is a feasible and effective alternative to conventional loop stoma for the protection of a low colorectal anastomosis.
Ratio-based Resuscitation in Trauma Patients with Traumatic Brain Injury: Is There a Similar Effect?
Authors: Jokar Tahereh Orouji , Khalil Mazhar , Rhee Peter , Kulvatunyou Narong , Pandit Viraj , O'Keeffe Terence , Tang Andrew , Joseph Bellal
Published: June 2020

The use of 1:1:1 (packed red blood cells: fresh frozen plasma: platelets) transfusion ratio has been shown to improve survival in severely injured trauma patients. The aim of this study was to assess the outcomes in patients with traumatic brain injury (TBI) receiving 1:1:1 ratio-based blood product transfusion (RBT). We hypothesized that RBT improves survival in patients with TBI as only major injury. We performed a 3-year retrospective analysis of all patients with TBI as only major injury presenting to our Level I trauma center. Patients receiving blood transfusion were included. Patients were stratified into two groups: those who received RBT and those who did not receive RBT (No-RBT). The outcome measure was inhospital mortality. Multivariate logistic regression analysis was performed. A total of 189 patients were included of which 29 per cent (n = 55) received RBT. The mean age was 48 ± 24 years, median (range) Glasgow Coma Scale score was 12 (3–15), and median head abbreviated injury severity scale was 3 (3–5). The overall mortality rate was 28.5 per cent. Patients in the RBT group had a higher survival rate compared with the patients in the No-RBT group (83.6% vs 66.5%, P = 0.02). In conclusion, the survival benefit of RBT exists even in patients with TBI as major injury. Guidelines for the initial management of TBI patients should focus on the use of RBT. The beneficial effect of platelets in RBT among TBI patients requires further evaluation.
An Approach to the Management of Pleural Empyema with Early Video-assisted Thoracoscopic Surgery and Early Transition to Oral Antibiotic Therapy
Authors: Espinosa Claudia M. , Fallat Mary E. , Woods Charles R. , Weakley Kathryn E. , Marshall Gary S.
Published: June 2020

Practice variation exists in the management of children with bacterial pneumonia complicated by empyema. The success of video-assisted thoracoscopic surgery (VATS) versus chest tube insertion for drainage and fibrinolysis may be dependent on the stage of disease. There is little published experience with early transition to oral (PO) antibiotics, and many children are treated with intravenous (IV) antibiotics at home. To describe a cohort of children with pneumonia and empyema in a primarily rural state managed with early VATS and transition to PO antibiotics. This was a retrospective medical record review of children managed by the pediatric infectious diseases and surgery services at Kosair Children's Hospital from 2008 through 2012. Sixty-one children met inclusion criteria. The majority underwent VATS on the first or second hospital day. No organism was identified in 67 per cent of cases. All patients received IVantibiotics at admission and all were discharged on PO antibiotics. The median time to transition was five days (interquartile range [IQR], 4–6), and the median duration of PO therapy was 16 days (IQR, 14–21). Ninety-eight per cent did not require further IV therapy. There were no deaths and clinical outcomes were good. In conclusion, children with pneumonia and empyema can be managed effectively with early VATS and early transition from IV to PO antibiotic therapy.
Clinicopathologic Review of 31 Cases of Solid Pseudopapillary Pancreatic Tumors: Can We Use the Scoring System of Microscopic Features for Suggesting Clinically Malignant Potential?
Authors: Kim Jang-hee , Lee Jae-myeong
Published: June 2020

A solid pseudopapillary tumor (SPT) is a pancreatic neoplasm of low malignant potential. The potentially malignant pathologic features of SPTs were regarded as angioinvasion, perineural invasion, deep invasion of the surrounding acinar tissue, and nuclear pleomorphism. We retrospectively reviewed 31 cases of SPTs (25 female and 6 male patients, with an average age of 35 ± 14 years). The mean follow-up period was 132.0 ± 55.9 months. To evaluate the clinical impact of above pathological parameters, we analyzed their correlation with actually observed clinical malignancy. In three cases, the SPTs were clearly clinically malignant: one patient had recurrences three times, one showed lymph node metastases, and one deep soft tissue invasion around the gastroduodenal artery. Tumor infiltration to the peripancreatic soft tissue was observed in 17 cases (54.8%). The pathologic features considered suggestive of malignant potential were angioinvasion (25.8%), perineural invasion (6.5%), presence of mitosis in 10 high-power fields (16.1%), and moderate nuclear pleomorphism (19.4%). The presence of at least three of these features was not correlated with clinically confirmed malignant behavior ( P = 0.570). Microscopic pathologic features of SPTs cannot be reliably associated with aggressive clinical behavior. Moreover, the absence of these microscopic features cannot exclude clinical malignancy.
A Prospective Blinded Study Evaluating the Role of Endoscopic Ultrasound before Endoscopic Retrograde Cholangiopancreatography in the Setting of “Positive” Intraoperative Cholangiogram during Cholecystectomy
Authors: Luthra Anjuli K. , Aggarwal Vipul , Mishra Girish , Conway Jason , Evans John A.
Published: June 2020

During laparoscopic cholecystectomy, intraoperative cholangiography (IOC) is used to identify common bile duct (CBD) stones. In patients whose IOC is suspicious for stones, endoscopic retrograde cholangiopancreatography (ERCP) is the modality of choice for stone removal. However, IOC has a false positive rate of 30 to 60 per cent, and ERCP adverse events may occur in 11 per cent of patients. Endoscopic ultrasound (EUS) may serve as a noninvasive means of diagnosing suspected CBD stones. This study sought to assess the role of EUS in predicting the likelihood of choledocholithiasis at ERCP in patients found to have a positive IOC. This was a prospective blinded study of EUS before ERCP in patients with a positive IOC. Recruited subjects who underwent cholecystectomy and had an IOC with suspicion for obstruction were referred for ERCP within one month of their procedure. In patients with a positive IOC, EUS had a positive predictive value of 95 per cent in detecting choledocholithiasis. IOC with single or multiple filling defects more often correlated to the presence of CBD stones. At ERCP, choledocholithiasis was present in 65 per cent of patients who had an IOC suspicious for CBD stones. EUS should be used as a noninvasive method to correctly identify retained CBD stones in low-to-moderate risk patients with a positive IOC.
The Prognostic Value of Circumferential Resection Margin Involvement in Patients with Extraperitoneal Rectal Cancer
Authors: Shin Dong Woo , Shin Jin Yong , Oh Sung Jin , Park Jong Kwon , Yu Hyeon , Ahn Min Sung , Bae Ki Beom , Hong Kwan Hee , Ji Yong Il
Published: June 2020

The prognostic influence of circumferential resection margin (CRM) status in extraperitoneal rectal cancer probably differs from that of intraperitoneal rectal cancer because of its different anatomical and biological behaviors. However, previous reports have not provided the data focused on extraperitoneal rectal cancer. Therefore, the aim of this study was to examine the prognostic significance of the CRM status in patients with extraperitoneal rectal cancer. From January 2005 to December 2008, 248 patients were treated for extraperitoneal rectal cancer and enrolled in a pro-spectively collected database. Extraperitoneal rectal cancer was defined based on tumors located below the anterior peritoneal reflection, as determined intraoperatively by a surgeon. Cox model was used for multivariate analysis to examine risk factors of recurrence and mortality in the 248 patients, and multivariate logistic regression analysis was performed to identify predictors of recurrence and mortality in 135 patients with T3 rectal cancer. CRM involvement for extraperitoneal rectal cancer was present in 29 (11.7%) of the 248 patients, and was the identified predictor of local recurrence, overall recurrence, and death by multivariate Cox analysis. In the 135 patients with T3 cancer, CRM involvement was found to be associated with higher probability of local recurrence and mortality. In extraperitoneal rectal cancer, CRM involvement is an independent risk factor of recurrence and survival. Based on the results of the present study, it seems that CRM involvement in extraperitoneal rectal cancer is considered an indicator for (neo)adjuvant therapy rather than conventional TN status.
An Imaging Diagnostic Protocol in Children with Clinically Suspected Acute Appendicitis
Authors: Epifanio Matias , De Medeiros Lima Marco Antonio , Corrêa Patricia , Baldisserotto Matteo
Published: June 2020

The objective of the present study is to evaluate a new diagnostic strategy using clinical findings followed by ultrasound (US) and, in selected cases, MRI. This study included 166 children presenting signs and symptoms suggesting acute appendicitis. Cases classified as suggesting appendicitis according to clinical exams had to be referred to surgery, whereas the other cases were discharged. Unclear cases were evaluated using US. If the US results were considered inconclusive, patients underwent MRI. Of the 166 patients, 78 (47%) had acute appendicitis and 88 (53%) had other diseases. The strategy under study had a sensitivity of 96 per cent, specificity of 100 per cent, positive predictive value of 100 per cent, negative predictive value of 97 per cent, and accuracy of 98 per cent. Eight patients remained undiagnosed and underwent MRI. After MRI two girls presented normal appendixes and were discharged. One girl had an enlarged appendix on MRI and appendicitis could have been confirmed by surgery. In the other five patients, no other sign of the disease was detected by MRI such as an inflammatory mass, free fluid or an abscess in the right iliac fossa. All of them were discharged after clinical observation. In the vast majority of cases the correct diagnosis was reached by clinical and US examinations. When clinical assessment and US findings were inconclusive, MRI was useful to detect normal and abnormal appendixes and valuable to rule out other abdominal pathologies that mimic appendicitis.
Laparoscopic Adrenalectomy for Adrenal Cancer—A Systematic Review
Authors: Sautter Amanda E. , Cunningham Steven C. , Kowdley Gopal C.
Published: June 2020

Laparoscopic adrenalectomy is increasingly employed for removal of adrenal masses. As adrenal tumors increase in size, however, their malignant potential likewise increases, raising concerns for the use of laparoscopy for removal of large adrenal malignancies. We present a systematic review of the use of laparoscopic adrenalectomy of large malignant tumors. A PubMed search was undertaken and two independent reviewers reviewed the manuscripts and a methodological index for nonrandomized studies score was determined. Manuscripts with scores greater than eight were included. The primary end points were rate of cancer recurrence, rate of conversion to open, complications, and surgical technique. Our initial search produced 412 manuscripts. After abstract review, 44 manuscripts were scored, of which 19 manuscripts were used. A total of 2183 tumors were removed, of which 517 were malignant. Average follow-up time was 38.7 months. The recurrence rate was 12.9 per cent. The rate of conversion was 3.6 per cent. The main techniques used were transabdominal and retroperitoneal. No significant differences in rate of recurrence or complications were seen when compared with open. Laparoscopic adrenalectomy may be performed for large and malignant tumors; however, most manuscripts on this subject lack significant scientific rigor and follow-up.
Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma
Authors: Smith Jason W. , Nash Nick , Procter Levi , Benns Matthew , Franklin Glen A. , Miller Keith , Harbrecht Brian G. , Bernard Andrew C.
Published: June 2020

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3–2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2–3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.