bluuebunny/crossref_metadata_2025 huggingface dataset:
The False Negative Technetium-99m-Sestatnibi Scan in Patients with Primary Hyperparathyroidism: Correlation with Clinical Factors and Operative Findings
Authors: Merlino James I. , Kichul Ko , Minotti Anthony , McHenry Christopher R.
Published: November 2022

False negative (FN) results limit the efficacy of technetium-99m-sestamibi scanning for parathyroid localization. We determined the incidence of FN results and attempted to correlate it with clinical and operative findings. One hundred forty-six patients underwent parathyroidectomy; 89 had primary hyperparathyroidism (76 single adenoma and 13 multiglandular disease) and underwent sestamibi scanning. The false negative rate was 22 per cent with an overall sensitivity of 77 per cent and a positive predictive value of 99 per cent. Patients with single adenomas were more likely to have a true positive scan than those with multiglandular disease [83% vs 38%; odds ratio (OR) = 7.754, 95% confidence interval (CI) = 2.184–27.524; P ≤ 0.0001]. Inferior adenomas (90% vs 59%; OR = 6.261,95% CI = 2.037–19.243; P ≤ 0.0001) and larger adenomas (1422.3 ± 1576.2 vs 474.6 ± 193.2 g; P ≤ 0.0001) were more likely to be detected by sestamibi imaging. Patients with normal preoperative calcium levels were more likely to have an FN sestamibi scan. Sestamibi parathyroid imaging is limited by a 22 per cent FN rate and is less accurate for detecting abnormal parathyroid tissue in patients with small adenomas, multiglandular disease, superior adenomas, or preoperative normocalcemia.
Severity of Cervical Spine Ligamentous Injury Correlates with Mechanism of Injury, Not with Severity of Blunt Head Trauma
Authors: Albrecht Roxie M. , Malik Salman , Kingsley Darra D. , Hart Blaine
Published: November 2022

Clearance of the cervical spine (CS) in obtunded trauma patients in an intensive care unit is problematic. Patients with no osseous injuries have potential unstable extradural supportive soft tissue injury. Evaluation of the supporting structures involves dynamic fluoroscopy or MRI both of which have inherent risks and convenience issues. Defining which of these patients are at highest risk for severe supportive structure injury may improve resource utilization for CS clearance. The purpose of this study was to evaluate clinical factors that may predict the probability of CS supportive soft tissue injury in patients with traumatic brain injury. Patients who sustained traumatic brain injury with intracranial pathology, absence of CS osseous injury, and a limited cervical spine MRI within 72 hours of injury were included. Potential clinical predictors included the severity of the traumatic brain injury defined by the Abbreviated Injury Severity Score for the cerebrum and initial Glasgow Coma Scale, the Injury Severity Score (ISS), mechanism of injury, and high versus low-velocity mechanism. Severity of soft tissue/ligament injury was graded by MRI findings. One hundred twenty-five patients met the study criteria; 81 had negative MRI findings and in 44 the MRI study was positive for potentially unstable injuries. High-velocity mechanisms of injury and ISS—not the severity of the traumatic brain injury or initial Glasgow Coma Scale score—were statistically significant predictors of severe CS supportive soft tissue injuries. Obtunded blunt trauma patients who have been involved in high-velocity-mechanism incidents and have high ISS are at greatest risk for extradural supportive soft tissue CS injuries. These patients should either remain in CS immobilization until clinical evaluation can be completed or undergo further evaluation of their supportive soft tissue structures by MRI or fluoroscopic flexion/extension.
Clinical impact of Micrometastasis of the Lymph Node in Gastric Cancer
Authors: Ishigami Sumiya , Natsugoe Shoji , Tokuda Koki , Nakajo Akihiro , Higashi Hiroshi , Watanabe Teruhiko , Aridome Kuniaki , Hokita Shuichi , Aikou Takashi
Published: November 2022

Micrometastasis in regional lymph nodes has been observed immunohistochemically, but the biological and clinical roles of minute nodal invasion of carcinoma in gastric cancer remain unclear. We used the anti-cytokeratin (AE1/AE3) antibody to immunohistochemically detect nodal micrometastatic lesions that could not be identified by routine pathological examination. A total of 4203 lymph nodes were examined in 180 gastric cancer patients. Lymph node metastasis was found in 36 of the 180 patients by routine pathological evaluation. Immunohistochemically micrometastasis was detected in the lymph nodes of 19 node-negative patients. Micrometastasis was not detected in any of the mucosal gastric cancer patients who underwent lymph node dissection. Gastric cancer patients with more than six metastatic lymph nodes all had nodal micrometastasis. Patients with micrometastasis had a significantly poorer survival rate than those without micrometastasis ( P < 0.05). Based on the present results the presence of lymph node micrometastasis may provide a more accurate indication for surgical outcome in gastric cancer patients at the same clinical stage.
Are you Ready to Become a Robo-Surgeon?
Authors: Patel Yatin R. , Donias Harry W. , Boyd Douglas W. , Pande Ravi U. , Amodeo Jeffery L. , Karamanoukian Raffy L. , D'Ancona Giuseppe , Karamanoukian Hratch L.
Published: November 2022

Robotic and minimally invasive surgery represents the future of modern surgical care. However, its role during the training of surgical residents has yet to be investigated. A previous study conducted by our group surveyed program directors at accredited general surgery training programs in the United States to determine the prevalence and application of robotics in their residency programs. This current study is a follow-up survey sent to residents across the United States to see whether they were being adequately trained and exposed to robotic surgery during their training. A survey was sent to 1800 general surgery residents, and their responses were tabulated and analyzed. Twenty-three per cent of the 1800 residents responded to our survey. An overwhelming 57 per cent of the responders indicated a high interest in robotic surgery. However, 80 per cent of the responders indicated not having a robotic training program. Robotic surgery has led to many promising advancements within the surgical subspecialties. With this emerging technology comes the need for a greater emphasis on the training of surgeons in robotics during their residency.
Accurate Diagnosis of Infarction of Omentum and Appendices Epiploicae by Computed Tomography
Authors: Abadir Janet S. , Cohen Allen J. , Wilson Samuel E.
Published: November 2022

Segmental infarction of the omentum and epiploic appendages presents with acute abdominal findings that may be confused with a surgical illness. Computed tomography, however, demonstrates a consistent and well-recognized pattern that allows safe, nonoperative treatment. Infarction of omental or mesenteric fat may present clinically as localized peritonitis, mimicking appendicitis, diverticulitis, or cholecystitis. Spontaneous recovery without operation is to be expected if an accurate diagnosis is established. We describe the diagnosis, treatment, and outcome of 15 patients who had infarction of the greater omentum (eight) and epiploic appendage (seven) and presented with localized abdominal pain and tenderness, with six demonstrating regional peritonitis and fever. All underwent CT imaging during their initial evaluation, and 12 of the 15 patients were diagnosed with focal omental or mesenteric fat infarction radiographically and managed nonoperatively. Three patients who had characteristic CT. findings nevertheless underwent operation. All patients had complete resolution of their abdominal pain regardless of treatment. The clinical presentation of infarction of the omental or epiploic appendages may be difficult to differentiate from surgical causes of acute abdominal pain. The characteristic findings on computed tomography are diagnostic and allow safe, conservative management in the majority of patients.
Sentinel Lymph Node Mapping of Breast Cancer: A Case-Control Study of Methylene Blue Tracer Compared to Isosulfan Blue
Authors: Eldrageely Kamal , Vargas M. Perla , Khalkhali Iraj , Venegas Rose , Burla Melissa , Gonzalez Katherine D. , Vargas Hernan I.
Published: November 2022

Isosulfan blue has been traditionally used as a tracer to map the lymphatic system during identification of the sentinel lymph node. However, allergic reactions may be life threatening. We compared the efficacy of methylene blue dye as a tracer for sentinel lymph node biopsy to isosulfan blue dye. In an analysis of 164 cases, there was no clinical or statistically significant difference in the success rate of sentinel node biopsy ( P = 0.22), the number of blue sentinel nodes harvested ( P = 0.46), the concordance with radioactive sentinel nodes ( P = 0.92), or the incidence of metastases ( P = 0.87) when methylene blue tracer was compared to isosulfan blue. No adverse reaction to either blue dye was observed. In conclusion, intraparenchymal injection of methylene blue dye is a reliable tracer for the lymphatic system and nodal identification during sentinel node mapping for breast cancer. It is safe, inexpensive, and readily available.
Axillary Recurrence in DCIS: Is Axillary Lymphadenectomy Warranted?
Authors: Trisal Vijay , Qian Dajun , Wagman Lawrence D.
Published: November 2022

Widespread use of screening mammography has resulted in a remarkable increase in the incidence (or detection rate) of ductal carcinoma in situ (DCIS). Axillary lymph node involvement in DCIS is reported to occur at a frequency of 1–12 per cent. Over the past few years, however, there has been increasing emphasis on axillary sampling, limited axillary dissection, and the potential role of sentinel lymph node biopsy. The clinical relevance of axillary lymph node biopsy or dissection remains unanswered. This retrospective analysis was performed on 171 patients who underwent treatment for DCIS at a tertiary care center over a period of 14 years. Clinical and tumor factors were evaluated, and the local, axillary, and systemic recurrence rates were noted. No axillary recurrences from the primary DCIS diagnosis were noted in the entire group of 171 patients. During a mean follow-up of 70 months, 10 patients (6%) developed recurrence in the ipsilateral breast. Six of these recurrences were in the form of DCIS, whereas, four recurred as invasive cancers. Nine patients developed a new primary (seven DCIS and two invasive) in the same breast but in a different quadrant. Two patients with ipsilateral invasive disease also developed systemic disease and eventually died of disease. During the same period, 10 patients (6%) developed DCIS, and seven patients (4%) developed invasive cancer in the contralateral breast. The data show that the risk of axillary recurrence in pure DCIS is, at most, extremely low and support the position that nodal sampling or dissection is unwarranted.
Lymphatic Mapping Improves Staging and Reduces Morbidity in Women Undergoing Total Mastectomy for Breast Carcinoma
Authors: Langer Samantha , Guenther J. Michael , Haigh Philip I. , Difronzo L. Andrew
Published: November 2022

Lymphatic mapping (LM) and sentinel lymph node biopsy (SLNB) have become widely accepted in the setting of breast conservation surgery. We hypothesized that LM can be extended to women undergoing total mastectomy, being technically feasible, yielding highly accurate and sensitive results, improving axillary staging, and reducing postoperative morbidity. Between 1995 and 2003, 99 women (mean age 59 years, range 34–87) underwent 100 mastectomies with LM using blue dye alone. Fifty-nine operations (60%) were followed by a completion axillary lymph node dissection (ALND). Ninety per cent of patients had invasive carcinoma; 10 per cent had in situ carcinoma. Mean tumor size was 2.5 cm (range 0.3–8 cm). One hundred fifty-nine sentinel nodes (SNs) (mean 1.65, range 1–5) were successfully identified in 96 (96%) axillae. Twenty-five (25%) sentinel nodes revealed nodal metastases. Five of 25 (20%) SNs had micrometasteses. Three patients had a false-negative SN, yielding a sensitivity of 91 per cent. The accuracy of LM was 97 per cent. No patient who underwent SLNB alone developed lymphedema, axillary seroma formation, infection, or restricted arm movement. This was contrasted with patients undergoing ALND, where 10 (16%) developed lymphedema and 2 (3%) developed an infection. Ten (25%) patients developed axillary paresthesias after SNB compared with 47 (78%) patients after ALND ( P < 0.0001). LM in the setting of mastectomy is accurate and sensitive. This technique improves axillary staging and decreases morbidity. Patients who are not candidates for breast conservation should be offered LM and SLNB at the time of mastectomy.
Rhabdomyolysis after Penetrating Trauma
Authors: Brown Carlos V.R. , Rhee Peter , Evans Kelly , Demetriades Demetrios , Velmahos George
Published: November 2022

Rhabdomyolysis (RHAB) is a known complication following blunt trauma. RHAB after penetrating trauma has not been studied. The objective of this study was to evaluate the incidence, risk factors, and complications of RHAB following penetrating trauma. Over a 5-year period, penetrating trauma patients admitted to our intensive care unit (ICU) were studied. Significant RHAB was defined as a CK level of 5000 U/L or higher. There were 873 patients (29 ± 12 years old, 92% male), of whom 767 (88%) had abnormal CK levels (range 520–165,943 U/L), and 111 patients (13%) developed significant RHAB. Victims of penetrating trauma who sustain vascular and severe extremity injury are at a sixfold increased risk to develop significant RHAB. Patients with significant RHAB had a higher rate of renal failure (23% vs 7%, P < 0.0001) and longer ICU stay (15 ± 26 days vs 8 ± 12 days, P < 0.0001). CK elevations and significant RHAB are common after penetrating trauma. Patients who sustain vascular and severe extremity injury as a result of their penetrating wounds are at high risk to develop significant RHAB, resulting in renal failure and prolonged ICU stay. Therefore, critically injured penetrating trauma patients should be routinely screened with CK levels.
Abdominal Approach to Chronic Diaphragmatic Hernias: Is it Safe?
Authors: Murray James A. , Weng Janie , Velmahos George C. , Demetriades Demetrios
Published: November 2022

Standard teaching has been to approach chronic diaphragmatic hernias (CDH) via a thoracotomy. It has been our experience that CDH can be safely approached via an abdominal incision. The objective of this study was to evaluate the outcome of patients undergoing the transabdominal approach for repair of CDH and comparing the outcome with that of patients undergoing a transthoracic (TT) approach. This is a retrospective chart review and was performed of patients with CDH secondary to trauma. Patient demographics, presenting symptoms, operative approach, and complications were collected. Patients were stratified by the surgical approach, TA versus TT. The endpoints of analysis were need for second incision, intraoperative and postoperative complications (enterotomies, pneumonia), need for a chest tube, mechanical ventilation postoperatively, and ICU and hospital days. Twenty-eight patients with CDH repairs performed between Jan 1993 and Dec 2002 were identified. Nineteen patients were in the TA group, and nine were in the TT group. Patients in the TA group had a higher incidence of emergent surgery (68% vs 11%, P = 0.005) and had a lower incidence of postoperative pneumonia (0% vs 33%, P = 0.009). No case of enteric injury from lysis of adhesions in the chest was identified. The need for a second incision (11%), the mortality (11%), ICU stay, and hospital stay were the same between the two groups. It appears that repair of CDH can be performed safely through an abdominal approach.
Radiological Studies after Laparoscopic Roux-en-Y Gastric Bypass: Routine or Selective?
Authors: Lyass Sergey , Khalili Theodore M. , Cunneen Scott , Fujita Fumihiko , Otsuka Koji , Chopra Ritu , Lahmann Brian , Lublin Matthew , Furman Gary , Phillips Edward H.
Published: November 2022

Early detection of complications after laparoscopic Roux-en-Y gastric bypass (LRYGB) can be difficult because of the subtle clinical findings in obese patients. Consequently, routine postoperative upper gastrointestinal contrast studies (UGI) have been advocated for detection of leak from the gastrojejunostomy. The medical records of 368 consecutive patients undergoing LRYGB were analyzed to determine the efficacy of selective use of radiological studies after LRYGB. Forty-one patients (11%) developed signs suggestive of complications. Of the 41 symptomatic patients, two were explored urgently, 39 (10%) had radiological studies, and 16 of them (41%) were diagnosed with postoperative complications. Overall morbidity of the series was 4.8 per cent. Four patients (1.1%) developed a leak from the gastrojejunostomy and were correctly diagnosed by computerized tomography (CT). The sensitivity and specificity of CT in determining leak was 100 per cent, with positive and negative predictive value of 100 per cent. The mortality of the series was 0 per cent. No radiologic studies were performed in asymptomatic patients, and no complications developed in these patients. Our results show that selective radiological evaluation in patients with suspected complications after LRYGB is safe. High sensitivity makes CT the test of choice in patients with suspected complication after LRYGB. Routine radiological studies are not warranted.
Diverticulitis: Truly Minimally Invasive Management
Authors: Macias Luis H. , Haukoos Jason S. , Dixon Matthew R. , Sorial Ehab , Arnell Tracey D. , St Amos Michael J. , Kumar Ravin R.
Published: November 2022

The purpose of this study is to evaluate the treatment of patients with acute diverticulitis in the inpatient setting using minimal intervention. This was a retrospective study of 75 patients admitted over a 3-year period with acute diverticulitis as evidenced by computed tomography (CT) and clinical scenario. Of the patients enrolled, 24 (32%) had abscesses identified on their initial CT scan. An additional four patients had abscesses noted on a subsequent CT scan obtained because of lack of complete improvement with medical management, thus raising the total number of abscesses to 28 (37%). Of the patients with abscesses, 10 (36%) underwent drainage using a CT-guided percutaneous or ultrasound-guided transrectal approach an average of 6 days after admission. Of the 75 patients, five (7%) required operative intervention during the initial hospitalization for failure of medical management, two (40%) of whom had abscesses on presentation. The overall median length of hospitalization was 5 (interquartile range [IQR] 4–9) days, and 18 patients (24%) had recurrences during the study period. Our conservative approach to percutaneous and surgical intervention resulted in relatively low percutaneous drainage, a low operative rate, and a reasonable length of hospitalization and recurrence rate.
Ex Vivo Lymphatic Mapping: A Technique to Improve Pathologic Staging in Colorectal Cancer
Authors: Broderick-Villa Gregory , Amr Dena , Haigh Philip I. , O'Connell Theodore X. , Danial Tarek , Difronzo L. Andrew
Published: November 2022

Sentinel lymph node (SLN) biopsy is widely used for solid tumors and has been proposed for use in staging colorectal cancer (CRC). Few studies have examined the ex vivo lymphatic mapping (EVLM) technique for staging CRC. We hypothesized that EVLM is technically feasible, sensitive, accurate, and improves the staging of CRC. After standard resection for colorectal cancer, 1 mL of isosulfan blue dye was injected circumferentially around the tumor. Blue-stained nodes were dissected separately and examined by hematoxylin and eosin (H&E) and immunohistochemical (IHC) stains. Routine pathologic evaluation was performed on all other harvested lymph nodes. Forty patients underwent 43 cancer resections with EVLM from July 2000 to December 2003. SLN were identified in 39 of 43 (91%) specimens. The mean number of SLN obtained was 1.9 (range, 0–5). Pathologic evaluation demonstrated nodal metastasis in 16 of 39 (39%) specimens. The SLN was tumor-positive in 9 of these 16 (56%) patients. The overall accuracy of EVLM was 82%. Two patients (9%) with H&E node negative disease were upstaged when found to have micrometastases by IHC staining. In conclusion, EVLM is technically possible in 90 per cent of patients with CRC. Although overall accuracy was high, the SLN status correlated poorly with the true nodal status of the CRC. However, EVLM improves pathologic staging in 9 per cent of patients and therefore may be of value in CRC.
Consider the Diagnosis of Splenosis for Soft Tissue Masses Long after Any Splenic Injury
Authors: Khosravi M.R. , Margulies D.R. , Alsabeh R. , Nissen N. , Phillips E.H. , Morgenstern L.
Published: November 2022

Splenosis represents the autotransplantation of splenic tissue after splenic trauma or surgery. Disruption of the splenic capsule causes fragments of splenic tissue to be seeded mainly throughout the peritoneal cavity, where they are characterized by diffusely scattered bluish implants. Extraperitoneal locations are very rare and mainly include the thoracic cavity after thoracoabdominal trauma with simultaneous splenic rupture and diaphragmatic laceration. We retrospectively identified all patients in the pathology registry with the diagnosis of splenosis between December 1974 and July 2003 at our urban teaching hospital. Data collected included presenting signs and symptoms, history, imaging studies, treatment, pathology, and outcome. Five cases of splenosis were identified and described. Location of the splenosis was intraperitoneal in two and intrahepatic, intrathoracic, and subcutaneous in one each. In these cases, there was an average interval of 29 years between splenic injury and diagnosis, and most were found incidentally. One of the cases was managed entirely laparoscopically and another thoracoscopically.
Unrecognized Foreign Body Ingestion: An Unusual Cause for Abdominal Pain in a Healthy Adult
Authors: Williams Christina , Mchenry Christopher R.
Published: November 2022

An unusual case of a unrecognized foreign body ingestion in a healthy, reliable adult patient is reported. A diagnosis of a foreign body perforation of the stomach was made on computed tomographic imaging of the abdomen that was obtained for evaluation of unremitting pain. This case emphasizes the importance of considering foreign body ingestion in the differential diagnosis for abdominal pain of unknown etiology.
Local Anesthetic Infusion Pumps Improve Postoperative Pain after Inguinal Hernia Repair: A Randomized Trial
Authors: Sanchez Barry , Waxman Kenneth , Tatevossian Raymond , Gamberdella Marla , Read Bruce
Published: November 2022

Pain after an open inguinal hernia repair may be significant. In fact, some surgeons feel that the pain after open repair justifies a laparoscopic approach. The purpose of this study was to determine if the use of local anesthetic infusion pumps would reduce postoperative pain after open inguinal hernia repair. We performed a prospective, double-blind randomized study of 45 open plug and patch inguinal hernia repairs. Patients were randomized to receive either 0.25 per cent bupivicaine or saline solution via an elastomeric infusion pump (ON-Q) for 48 hours, at 2 cc/h. The catheters were placed in the subcutaneous tissue and removed on postoperative day 3. Both groups were prescribed hydrocodone to use in the postoperative period at the prescribed dosage as needed for pain. Interviews were conducted on postoperative days 3 and 7, and patient's questionnaires, including pain scores, amount of pain medicine used, and any complications, were collected accordingly. During the first 5 postoperative days, postoperative pain was assessed using a visual analog scale. Twenty-three repairs were randomized to the bupivicaine group and 22 repairs randomized to the placebo group. In the bupivicaine group, there was a significant decrease in postoperative pain on postoperative days 2 through 5 with P values <0.05. This significant difference continued through postoperative day 5, 2 days after the infusion pumps were removed. Patients who had bupivicaine instilled in their infusion pump had statistically significant lower subjective pain scores on postoperative days 2 through 5. This significant difference continued even after the infusion pumps were removed. Local anesthetic infusion pumps significantly decreased the amount of early postoperative pain. Pain relief persisted for 2 days after catheter and pump removal.
Adenocarcinoma Arising in Rectal Duplication Cyst: Case Report and Review of the Literature
Authors: Shivnani Anand T. , Small William , Benson Al , Rao Sambasiva , Talamonti Mark S.
Published: November 2022

Duplication cyst of the gastrointestinal (GI) tract is a rare congenital anomaly, and rectal duplication cysts comprise a small fraction these cases. Most patients present for the first time in adulthood, and the origin of rectal duplication cysts is unclear. Prior series document malignant transformation in approximately 20 per cent of cases. The following case report describes a carcinoma arising in a rectal duplication cyst. Given the lack of data demonstrating adequate control for patients with adenocarcinoma arising in a rectal duplication cyst and our experience with this patient, we recommend all patients undergo multidisciplinary evaluation prior to any therapy.
Diagnostic Pathways and Delays on Route to Operative Intervention in Acute Appendicitis
Authors: Garfield Jamie L. , Birkhahn Robert H. , Gaeta Theodore J. , Briggs William M.
Published: November 2022

The purpose of this study was to determine the elements associated with delay in the evaluation of acute appendicitis at a community teaching hospital. We performed a retrospective chart review of patients undergoing operative exploration for presumed appendicitis in a 12-month period. Cases were categorized by the presence or absence of advanced radiographic imaging. Demographic information and time intervals from triage to operative incision were compared. One hundred twenty-four patients underwent operative exploration for presumed appendicitis. Forty-one patients had no advanced imaging, 67 had a CT scan, 8 had a sonogram, and 8 had both CT/sonogram. Patients using advanced radiographic imaging prior to operative exploration were no less likely to have a normal appendix at surgery. Diagnostic imaging significantly increased the preoperative emergency department length of stay. Two-thirds of patients with presumed acute appendicitis were imaged before operative exploration. The use of abdominal CT and sonogram resulted in significantly increased preoperative emergency department length of stay with no apparent improvement in diagnostic accuracy.
Anal Condyloma: A Comparison between HIV Positive and Negative Patients
Authors: Anderson C.A. , Boller A.M. , Richardson C.J. , Balcos E.G. , Zera R.T.
Published: November 2022

HIV positive and negative patients with anal condylomata were compared to determine an association with squamous cell neoplasia, its disease progression, and response to treatment. From 1992 to 2003, 61 patients were diagnosed with anal condylomata by anal biopsy. Thirty-four patients were HIV+ and 27 patients were considered HIV-. Upon retrospective chart review, details on disease progression, development of malignancy, and subsequent treatment were collected. Sixty-one per cent of HIV+ patients had a neoplastic process in contrast to 25 per cent of HIV- patients ( P = 0.005). Five patients demonstrated disease progression, of which four were HIV+. Three HIV+ patients were treated for invasive carcinoma with excision and standard chemoradiation therapy. Two patients with T3 lesions developed recurrence and died. Eighteen HIV+ patients had noninvasive carcinoma and were treated with local excision without recurrence at mean follow-up of 28 months. HIV+ patients were shown to have more condylomata harboring squamous cell neoplasia than HIV- patients. Noninvasive carcinoma can be treated effectively with local excision, independent of HIV status; however, long-term follow-up is needed. Chemoradiation therapy in patients who are relatively healthy and have stage I disease may be successful. The role for chemoradiation in AIDS patients with stage III disease remains unclear.
Utility of Falciform Ligament in Abdominal Surgery: A Systematic Review
Authors: Liu Tom , Saber Alan
Published: November 2022

Objective

The aim of the present systematic review was to assess current trends in use of falciform ligament in abdominal surgery.

Background

The falciform ligament has been proposed in surgical literature as a suitable pedicle or flap with acceptable surgical outcomes; however, it is underutilized in abdominal surgery.

Methods

We performed a literature search and meta-analysis. All English studies describing use of a falciform ligament were eligible for inclusion.

Results

Of the 547 articles mentioning use of falciform ligament, 32 full text articles were included in this review. The majority were case reports (n = 14). The mremaining papers included retrospective analysis (n = 10), randomized control trials (n = 2), reviews (n = 3), and technique descriptions (n = 6).

Conclusion

The falciform ligament appears to be a safe and easily accessible natural tissue with a variety of surgical applications. It is most useful as a pedicle flap and could have benefit in foregut surgery including hepatic, pancreatic, biliary, gastric, and esophageal operations.
Early Ambulation is Associated with Improved Outcomes Following Colorectal Surgery
Authors: Rosowicz Andrew , Brody Jason S. , Lazar Damien J. , Bangla Venu G. , Panahi Armon , Nobel Tamar B. , Dexter-Meldrum Jacob , Divino Celia M.
Published: November 2022

Background

The Enhanced Recovery After Surgery (ERAS) society lists early mobilization as one of their recommendations for improving patient outcomes following colorectal surgery. The level of supporting evidence, however, is relatively weak, and furthermore, the ERAS guidelines do not clearly define “early” mobilization. In this study, we define mobilization in terms of time to first ambulation after surgery and develop an outcome-based cutoff for early mobilization.

Methods

This is a retrospective cohort study comprised of 291 patients who underwent colorectal operations at a large, academic medical center from June to December 2019. Three cutoffs (12 hours, 24 hours, and 48 hours) were used to divide patients into early and late ambulation groups for each cutoff, and statistical analysis was performed to determine differences in postoperative outcomes between the corresponding groups.

Results

Multivariate analysis showed no difference between the early and late ambulation groups for the 12-hour and 48-hour cutoffs; however, ambulation before 24 hours was associated with a decreased rate of severe complications as well as fewer adverse events overall. Patients who ambulated within 24 hours had a 4.1% rate of severe complications and a 22.1% rate of experiencing some adverse event (complication, return to the emergency department, and/or readmission). In comparison, 11.8% of patients who ambulated later experienced a severe complication ( P = 0.026), while 36.1% of patients experienced some adverse event ( P = 0.011).

Conclusions

Ambulation within 24 hours after colorectal surgery is associated with improved postoperative outcomes, particularly a decreased rate of severe complications.
Leiomyosarcoma of the Colon: A Second Malignant Neoplasm after Treatment for a Wilms’ Tumor
Authors: Johnson Melissa A. , Gibbs David H. , Gouldman John , Hanly Mark , Gadacz Thomas R.
Published: November 2022

Leiomyosarcoma of the colon is a rare malignancy. We report the case of a 33-year-old woman with a leiomyosarcoma of the colon occurring as an intussusception 30 years after receiving abdominal irradiation for a Wilms’ tumor. A review of the prior and current treatment for Wilms’ tumor is discussed, as well as the association between second malignancies and abdominal irradiation. Leiomyosarcoma of the colon usually presents in the fifth and sixth decades of life and is more common in men. The most common symptom is pain. Ninety per cent are diagnosed at surgery for treatment of bleeding, perforation, or obstruction. Surgery remains the primary treatment. Leiomyosarcomas of the gastrointestinal tract are radioresistant, and adjuvant chemotherapy has shown no survival benefit. The overall prognosis is poor, with mean 5-year survival of 28 per cent. General surgeons need to be aware of the possibility of second malignant neoplasms after primary treatment of childhood cancers. Proper reporting is essential to study the long-term effects of early treatment of childhood cancers and in predicting the best treatment outcomes for these patients.
Laparoscopic Omental Patch Repair for Perforated Duodenal Ulcer
Authors: Kok Kenneth Y. Y. , Mathew V. V. , Yapp Samuel K. S.
Published: November 2022

A retrospective review was carried out on 33 consecutive patients with omental patch repair for perforated duodenal ulcer; 13 had laparoscopic repair, and 20 had open repair. Laparoscopic repair was successful in 12 patients, with only one postoperative complication (8%). The morbidity rate for open repair was 15 per cent (3 of 20), and there was one postoperative death in the open group (5%). Overall, it did not take longer to perform the operation laparoscopically than the open method. Patients in the laparoscopic group required less postoperative analgesia (mean doses, 0.2 vs 0.9; P = 0.02). There was no difference in terms of hospital stay and resumption of diet after operation between the two groups. Laparoscopic omental patch repair offers a safe alternative to the open method in the treatment of perforated duodenal ulcer.
Increased Efficiency and Cost-Effectiveness in the Evaluation of the Blunt Abdominal Trauma Patient with the Use of Ultrasound
Authors: Arrillaga Abenámar , Graham Robin , York John W. , Miller Richard S.
Published: November 2022

The efficacy and effectiveness of ultrasound (US) in evaluating patients suspected of having blunt abdominal trauma are near that of computed tomography (CT) and diagnostic peritoneal lavage (DPL). Because no cost-effectiveness study has been reported, the purpose of this study was to demonstrate that US is more efficient and cost-effective than CT/DPL in evaluating blunt abdominal trauma. Over a 9-month period, 331 patients suspected of sustaining blunt abdominal trauma were evaluated at a Level I trauma center by US, CT, and/or DPL. Cost data and time to disposition were determined for analysis. The sensitivity, specificity, and accuracy of US were similar to those reported in previous studies. There was a significant difference in time to disposition with the US group being significantly lower (P = 0.001). The total procedural cost was 2.8 times greater for the CT/DPL group than for the US group. US is not only effective in diagnosing blunt abdominal trauma, but it is also more efficient and cost-effective than is CT/DPL.
Ileoanal Pouch Procedures: Clinical Outcomes and Quality-of-Life Assessment
Authors: Seidel Scott A. , Peach Shari E. , Newman Martin , Sharp Kenneth W.
Published: November 2022

Ileoanal pouch (IAP) anastomosis following total colectomy for ulcerative colitis or familial adenomatous polyposis is performed with the goal of avoiding a permanent ileostomy and its effects on life satisfaction. During a retrospective 10-year study period, 55 patients underwent IAP construction for ulcerative colitis (36) and familial adenomatous polyposis (19). We assessed complications by chart review and surveyed patients regarding quality of life via a standardized questionnaire. There was no operative mortality, and there were three late deaths (6%). Twenty-nine patients (54%) sustained 68 early and late complications. Pouchitis was the most common complication (24%), and two patients required pouch excision (4%), one for pouchitis and one for rectovaginal fistula. Thirty-one patients (65%) have completed questionnaires. Forty-seven patients (87%) responded that their overall quality of life is “always” better since creation of the IAP, and only one patient in the IAP group has greater than ten bowel movements a day. Twenty-one patients (68%) never have interference With intimate relationships and 20 (65%) never have interference with physical activities. However, 20 patients (65%) sometimes have sleep interference, and 19 patients (61%) sometimes have fecal soilage. None of the patients continue to take steroids. We conclude that the complication rate following IAP construction is high, but pouch loss is infrequent. Despite a high complication rate, the majority of patients experience an improvement in quality of life.
An Unusual Etiology of Biliary Hilar Obstruction and the Potential Role of Acidic Fibroblast Growth Factor in the Development of a Biliary Neuroma
Authors: Pickens Allan , Vickers Selwyn M. , Brown Kelvin L. , Reddy Vishnu V. B. , Thompson John A.
Published: November 2022

Neuroma of the biliary tract is a rare condition thought to be caused by trauma secondary to cholecystectomy. More rare is the occurrence that causes symptomatic biliary obstruction. A 65-year-old woman was hospitalized because of abdominal pain, nausea, vomiting, and general malaise of 1 to 2 months duration. Cholecystectomy had been performed 40 years before. Ultrasound revealed hepatomegaly and dilated intrahepatic ducts. CT showed intra- and extrahepatic ductal dilatation with questionable intraductal mass. Endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography demonstrated stricture of the hepatic duct bifurcation. The biliary bifurcation was resected, and hepaticojejunostomy was performed. The patient's postoperative course was unremarkable. Histological examination of the surgical specimen revealed positive staining for the S-100 antigen of the obstructing luminal stricture (without evidence of cholangiocarcinoma), which was consistent with a biliary neuroma. Positive staining was also found for acidic (and not basic) fibroblast growth factor (FGF) and two of its high affinity receptors (FGFR-1 and FGFR-4). This study supports the apparent association between biliary neuromas and cholecystectomy as well as the potential role of an established angiogenic and neurogenic growth factor in the formation of this tumor. Finally, this case is also unique in that it represents the longest interval between cholecystectomy and presentation of a biliary neuroma, 40 years after surgery.
Prospective, Randomized Evaluation of Early Removal of Nasogastric Tubes in Postceliotomy Trauma Patients
Authors: Knoepp Louis F. , Thomae Keith R.
Published: November 2022

The objective of this study is to compare early (24-hour) removal of nasogastric tubes (NGTs) in trauma patients who have undergone emergency celiotomy to removal based on clinical signs of return of bowel function. All trauma patients who underwent an emergency celiotomy between November 1994 and August 1997 were randomized to 24-hour NGT removal, or removal when flatus and decreased NG output indicated. Exclusion criteria included patients with duodenal or esophageal injuries, those with airway intubations that were >24 hours, or those who had undergone same-hospitalization repeat celiotomy. Gastric or severity of intestinal injury were not exclusion criteria. Failure of NGT removal was defined as pain, abdominal distention, and vomiting. Mechanisms of injury, Injury Severity Score, operative findings, NGT removal times, morbidity, laboratory data, and reasons for failure were evaluated. A total of 177 patients qualified for the study. Two patients were inappropriately randomized and subsequently excluded. Of the remaining 175 patients, 151 sustained penetrating injuries and 24 sustained blunt injuries. Of the 151 patients in the penetrating injury group, 68 were randomized to the 24-hour pull (study) group and 83 were randomized to the clinical pull (control) group. There were three failures in the study group [3 of 68 patients (4.4%)] and three failures in the control group [3 of 83 patients (3.6%)]. Of the 24 blunt injury patients, 10 were randomized to the study group and 14 were randomized to the control group. There was one failure in the study group [1 of 10 patients (10.0%)] and one failure in the control group [1 of 14 patients (7.1%)]. Overall failure rate for the study group was 5.1 per cent [(3+l)/(68+10) = 5.1%] versus 4.1 per cent for the control group. Overall failure for all patients in the study was 4.6 per cent. Injury severity score, morbidity, and lab values were not significantly different. It is safe to remove NGTs at 24 hours in most trauma patients regardless of the severity of injury (failure rate, 5.1%). The surgical dogma of the need to have an NGT in longer for blunt trauma was not revealed in this study, however, a larger study would be needed to determine this with significance.
Prevention of Postherniorrhaphy Urinary Retention with Prazosin
Authors: Gönüllü Neşet Nuri , Dülger Mustafa , Utkan Nihat Zafer , Cantürk Nuh Zafer , Alponat Ahmet
Published: November 2022

Urinary retention that necessitates catheterization after herniorrhaphy is a well known, but usually ignored, situation. Increased sympathetic activity resulting from surgery may be the contributing factor. Blockade of a receptors in the bladder neck and urethral sphinchter may prevent postoperative urinary retention. In this prospective placebo-controlled study, the efficacy of prazosin in preventing postoperative urinary retention after herniorrhaphy was investigated in 156 patients. Patients were randomized into two groups. Patients in Group I (control) were given placebo orally 12 hours before surgery, just before surgery, and 12 and 24 hours after surgery. In Group II, 1 mg of prazosin was given in the same manner of placebo. Nine of 84 patients (10.8%) in the prazosin group and 18 of 72 patients (25%) in the placebo group developed urinary retention. Catheterization was required in only 3 patients (3.5%) in the prazosin group compared to 10 patients (13.8%) in placebo-treated group (P < 0.05). In conclusion, prophylactic use of prazosin after herniorrhaphy significantly reduced the incidence of urinary retention and catheterization.
Marker Clip Placement following Directional, Vacuum-assisted Breast Biopsy
Authors: Reynolds Handel E.
Published: November 2022

The purpose of this study was to evaluate the accuracy of marker clip placement after 11-gauge directional, vacuum-assisted breast biopsies. During a 9-month period, 150 stereotactic breast biopsies were performed using a directional, vacuum-assisted device and an 11-gauge probe. In 114 cases, a marker clip was deployed at the biopsy site using the through-probe method. In 94 cases, stereotactic coordinates of the clip were obtained and were available for retrospective review. Comparing the coordinates of the lesion with those of the clip, placement errors were calculated. Overall, clip placement was within 5 mm of the lesion in 81 per cent of cases, within 5–10 mm of the lesion in 17 per cent of cases, and >10 mm from the lesion in 2 per cent of cases. Mean total placement error was 4.5 mm. The mean z axis error was 3.2 mm, compared with 0.88 and 2.0 mm for the x and y axes, respectively. Marker clip placement after vacuum-assisted biopsy is an accurate method of localizing the biopsy site should subsequent surgery be required.
Are Pancreatic Tumors Hormone Dependent?: A Case Report of Unusual, Rapidly Growing Pancreatic Tumor during Pregnancy, Its Possible Relationship to Female Sex Hormones, and Review of the Literature
Authors: Ganepola G. A. P. , Gritsman Andrey Y. , Asimakopulos Nicholas , Yiengpruksawan Anusak
Published: November 2022

The occurrence of a pancreatic tumor in a young patient is rare. However, when one identifies a pancreatic mass during pregnancy and particularly when the lesion is located in the tail of the pancreas, “unusual tumors” of the pancreas should be considered. The management of these tumors during pregnancy presents unusual challenges because of rapid tumor growth probably related to elevated levels of sex hormones. An immunohistochemical study was done to evaluate for hormone receptors of the tissue removed from the tumor. We present a case of a 37-year-old female patient in her 4th week of pregnancy who was found to have a pancreatic mass; she was followed with ultrasonography. At the 23rd week of gestation, the tumor increased in size to more than 12 cm and required resection. Immunohistochemical studies were done to evaluate receptors for progesterone, estrogen, PS2-estrogen-related protein, pancreatic polypeptide antigen, flow cytometry, DNA ploidy, and proliferative activity in tumor cells. Pathology showed a low-grade multiloculated mucinous cystic neoplasm of the pancreas. There was a positivity for progesterone receptor and PS2-estrogen-related protein but not for estrogen receptor in the tumor. We conclude that a pancreatic mass detected during pregnancy requires a different consideration for its management. Early tissue diagnosis with CT or ultrasound-guided biopsy is essential. Even those lesions diagnosed as benign would require early intervention because of their rapid growth, probably influenced by female sex hormones.
Presacral Cysts: Transrectal Excision in Select Patients
Authors: Pidala Mark J. , Eisenstat Theodore E. , Rubin Robert J. , Salvati Eugene P.
Published: November 2022

Fourteen patients presenting with presacral cystic lesions were managed over a 20-year period. Retrospective review identified 12 females and 2 males. Fifty-seven per cent were symptomatic at diagnosis. Forty-three per cent presented with pain; half of these patients had infected cysts. All lesions were palpable on digital rectal exam. Computed tomography identified the cyst in all seven patients in which it was performed. The transrectal approach was used for cyst excision in ten patients. One patient had transrectal drainage and wall biopsy only. Three patients underwent posterior parasacral excision. Pathologic review demonstrated four dermoid cysts, four epidermoid cysts, four cyst hamartomas, and two benign teratomas. One cyst hamartoma had a focus of invasive adenocarcinoma. Two complications occurred. There were no deaths. Follow-up averaged 39 months, at which time there were no recurrences. Developmental cysts are the most common presacral tumors. Excision is recommended, and the transrectal approach may be used in select patients with low morbidity and minimal recurrence.
Tuberculoma of the Spleen: A Rare but Important Clinical Entity
Authors: Bastounis Elias , Pikoulis Emanouil , Varelas Panayiotis , Cirochristos Dimitrios , Aessopos Athanassios
Published: November 2022

Tuberculoma of the spleen has been an extremely rare entity during the last decades in the Western world. We describe a case in a young, HIV-negative woman who was evaluated for fever of unknown origin. The workup was initially negative, and she was treated successfully with steroids and nonsteroidal anti-inflammatory analgesics. Recurrence of the fever and an abnormal CT of the abdomen lead to an exploratory laparotomy, which revealed a subcapsular caseous material containing splenic abscess. The very few cases reported in the literature, and the increasing incidence of extrapulmonary tuberculosis due to the alarming numbers of immunodeficient patients that a surgeon may encounter are also discussed.