The American Surgeon™

We sought to evaluate factors influencing the choice of surgery for women with early-stage breast cancer. Between 1996 and 2005, 47,837 women who were diagnosed with Stage I breast cancer underwent partial (PM) or total mastectomy (TM) in the California Cancer Registry. A total of 72.8 per cent of women underwent PM. Those treated in the most recent 5-year period were more likely to undergo PM than in the prior 5 years (76.5 vs 69.5%, P < 0.0001). PM rates increased with increasing socioeconomic status (SES): 65.1 per cent of patients in the lowest SES quintile underwent PM versus 77.2 per cent in the highest SES quintile (P < 0.0001). Forty- to 64-year-old women were more likely to receive PM compared with their older and younger counterparts (74.5 vs 71.2 and 67.0%, respectively; P < 0.0001). Asian/Pacific Islander women were least likely to undergo PM (64.0%), whereas non-Hispanic black women were most likely to undergo PM (75.0%) (P < 0.0001). On multivariate analysis, these demographic factors remained independent predictors of surgical treatment. PM rates have increased over time; however, significant differences in surgical management exist among women of different race/ethnic groups, ages, and SES. Further research is required to elucidate modifiable factors that impact the choice of surgery for women with early-stage breast cancer.

We sought to examine the significance of the number of nodes examined in node-positive colorectal cancer. Between January 1, 1994, and December 31, 2003, 7192 patients with colorectal cancer underwent potentially curative resection in Region 5 of the California Cancer Registry. Of these patients, 2636 patients were node-positive: 65.1 per cent were N1 and 34.9 per cent were N2. The median follow up was 39.5 months. The mean number of nodes examined was 10.4 (range, 1-89) for NO, 11.0 (range, 1-72) for N1, and 14.6 (range, 4-79) for N2 (P < 0.0001). N1 and N2 patients were stratified according to the percentage of positive nodes into quintiles (0.19 or less, 0.20 to 0.39, 0.40 to 0.59, 0.60 to 0.79, and 0.80 to 1.0). In both N1 and N2 disease, a lower percentage of lymph nodes involved with metastatic disease was associated with improved survival (P < 0.0001). The increasing ratio of positive to total nodes was the result of a decrease in the total number of nodes examined in N1 disease and a steeper decline in total nodes examined in relation to the increase in the number of positive nodes in N2 disease. The ratio of positive to total nodes has prognostic significance in node-positive colorectal cancer.

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

Emergent operation after renal transplantation (RT) has traditionally been associated with substantial morbidity and mortality. We reviewed 2340 adult patients who underwent RT at our tertiary care center and identified 55 patients who required acute care surgical consultation within 1 year of transplantation. Of these, 43 were treated operatively and 12 nonoperatively Primary diagnoses were intestinal problems in 29 patients (53%), including diverticulitis, ischemia, perforation, obstruction, and bleeding; cholecystitis in 10 (18%); fluid collections in six (11%), appendicitis and hernias in two each (4%); gastritis in one (2%); and no diagnosis in five (9%). Colonic pathology was treated with resection and diversion in 14 of 16 patients who underwent surgery. Acute allograft rejection preceded the surgical problem in five patients. Complications occurred in 13 per cent of patients, and mortality was 9 per cent. Colonic ischemia had a fulminating presentation and particular morbidity. We conclude that acute gastrointestinal emergencies after RT are rare and that early and aggressive intervention using an acute care surgical model yields excellent results.

Most colon cancer resections do not meet the 12-lymph node minimum recommended in 2001 National Cancer Institute (NCI) panel guidelines. Previous reports suggest surgical training influences lymph node recovery. We hypothesized that recent trends show improved results for lymphadenectomy regardless of specialty. The cancer registry database at a large community hospital with an academic surgical oncology training program was queried to identify resections performed for colon cancer before (1995 to 2000) and after (2001 to 2006) NCI guideline publication. There were no changes in pathology procedures between 374 early and 411 later procedures. The later period brought increases in mean total lymph nodes (15.4 vs 10.4, P < 0.0001), total positive nodes (1.8 vs 1.2, P = 0.005), and the percentage of procedures yielding 12 or more nodes (overall: 65.9 vs 36.0%, P < 0.0001; Stage II and III disease: 73.0 vs 41.4%, P < 0.003). In addition, mean nodal yield increased (P < 0.0001) for fellowship-trained surgeons (16.7 vs 11.2) and nonfellowship-trained surgeons (14.9 vs 10.2). Single-registry data show that since 2001, most colon resections exceed minimum recommendations for lymph node recovery regardless of surgical training. The increased rate of adequate lymphadenectomy for Stage II and III disease is encouraging because this patient population will benefit most by accurate staging of colon cancer.

With improving accuracy and efficiency of CT, some trauma centers have used a low threshold for the use of CT scans in the evaluation and assessment of trauma patients. The purpose of this study was to evaluate the diagnostic benefits of liberal CT scanning in multisystem blunt trauma motorcycle accident victims. The trauma registry at our community-based Level II center was accessed to identify consecutive motorcycle accident victims within a 55-month period who: 1) were evaluated on presentation by an attending trauma surgeon; and 2) underwent a head, cervical spine, chest, abdomen, or pelvis CT scan or any combination as part of their initial assessment. For those patients with clinically significant findings identified on CT, the percentage of those with negative clinical examinations was calculated. We found that 48, 77, 47, and 69 per cent of patients with clinically significant findings on head, cervical spine, thoracic, and abdominal CT, respectively, had normal clinical examinations. Our data suggest lower thresholds for CT use in the evaluation of patients sustaining multisystem blunt trauma should be adopted, even in the face of normal clinical examinations. This is especially true for the neck and abdominal regions.

Although the technical success rate of endoscopic stenting has been defined, there is a paucity of outcome data. The purpose of this study was to evaluate the long-term results of colorectal stenting for both malignant and benign disease. A retrospective review was conducted of patients who underwent stenting at a tertiary center over 4 years. One surgeon performed all stents under endoscopic and fluoroscopic guidance. A total of 49 stent procedures were performed in 36 patients (19 females, mean age 65 years). Mean follow-up was 15 months. Twenty-eight patients (78%) underwent stenting for malignant disease and eight patients (22%) for benign conditions. The most common reason for intervention was obstruction (81%). Technical success rate was 72 per cent. Carcinomatosis was associated with a higher technical failure rate. Procedural related complications occurred in two patients (6%). Long-term stent migration rate was 24 per cent and was more common in patients with benign disease and patients who received nonmetal stents or stents with diameter < 25 mm. Endoscopic reintervention was required in 33 per cent of patients with initial technical success. Long-term need for subsequent operative intervention was 14 per cent. Endoscopic stenting is a viable option for a select group of patients with colorectal disease. Patient's selection and stent choice influence outcome.

An increasing demand for transplant donor organs has made optimal allocation of resources a priority. Our objective was to evaluate outcomes for orthotopic liver transplantation (OLT) performed in the United States. A query of the United Network for Organ Sharing registry between 1988 and 2007 was performed for patients who underwent OLT for all etiologies. Patients were stratified by pathology necessitating OLT and clinical and pathologic factors were compared. Multivariate Cox-regression analysis was used to assess the association of pathology with survival. Of 61,823 patients, 33 per cent (n = 20,305) of OLTs were secondary to hepatitis C virus, 21 per cent autoimmune disease, 17 per cent alcohol-induced injury, 11 per cent cryptogenic cirrhosis, 8 per cent hepatocellular carcinoma (HCC), 6 per cent hepatitis B virus, and 4 per cent metabolic disease. Patients with autoimmune disease and HCC demonstrated the best and worst survival, respectively, after OLT (median survival 16.0 vs 6.4 yrs, respectively, P < 0.001). By multivariate analysis, OLT for HCC was significantly associated with poorer overall survival (hazard ratio [HR] 2.19,95% confidence interval [CI]: 2.02-2.37, P < 0.001). Our results indicate that outcomes for liver transplantation vary by primary hepatic pathology with HCC patients having the poorest overall survival. To optimize organ allocation for all patients with end-stage liver disease, a better understanding of poor survival for HCC is necessary.

Despite the prevalence of surgical candidates on clopidogrel, no definitive guidelines exist for stopping the drug preoperatively. A 7 day off-clopidogrel period is commonly considered safe with regards to bleeding complications. We sought to put the 7-day window to the test with regards to major bleeding events requiring either blood transfusions or return trips to the operating room. We collected data for patients taking clopidogrel in the perioperative period between 2005 and 2007 (n = 170). This data was then compared with the data of all of the patients undergoing surgery at our institution for the same time period (n = 34,480). Patients taking clopidogrel experienced a significantly higher rate of return trips to the operating room (6.5%) compared with nonclopidogrel patients (0.015%). Interestingly, we found no significant difference between those stopping clopidogrel more than 7 days preoperatively and those that did not (5% and 7.5%, respectively). There did not seem to be a significant difference in blood transfusion rates between the two clopidogrel groups. Patients on perioperative clopidogrel require reoperations for bleeding at a significantly higher rate compared with patients not taking clopidogrel. Discontinuing clopidogrel 7 days before surgery is not enough to negate this difference and these patients still experience a drastically higher rate of reoperations for bleeding.

Squamous cell carcinoma (SCO of the breast is an uncommon breast neoplasm. There are limited data about its epidemiology and few studies focusing on outcomes. This study aims to identify specific characteristics of patients with breast SCC, investigate its natural history, and determine its long-term prognosis. One hundred and seventy-seven cases of SCC of the breast were identified in the California Cancer Registry from the years 1988 to 2006. At the time of diagnosis, 53 per cent of patients had localized disease, 32 per cent of patients had regional lymph node or locally advanced disease, and 8 per cent of patients had distant disease. The relative cumulative survival of patients was 68.1 per cent at 5 years and 60.2 per cent at 10 years. This is significantly worse than the relative cumulative survival of patients with all other invasive breast tumors during the same time period. Squamous cell carcinoma of the breast is a rare and aggressive disease, and it has significantly worse prognosis than other nonsquamous cell tumors of the breast. Clinicians should be aware of the aggressive nature of the tumor when counseling patients.

Computed tomography (CT) diagnoses appendicitis accurately, but few studies evaluate how often CT changes the management of appendicitis. Consultations for appendicitis were evaluated by surgeons and assigned to groups: high, indeterminate, and low suspicion. After assignment, CT was reviewed if completed or ordered if desired by the surgeon and changes in plans were noted. One hundred patients were evaluated for appendicitis, 70 received appendectomy. Our negative appendectomy rate was 4 of 70 (5.7%). In the high suspicion group, 63 patients had 23 CT scans performed and 2 CT scans were negative, avoiding unnecessary operation and changing management in 2 of 63 (3.2%). The intermediate suspicion group included 27 patients and 26 CT scans performed; 11 were positive resulting in nine positive appendectomies and changing management in 9 of 27 (33%). The low suspicion group had 7 CT scans performed; two were positive leading to two positive appendectomies and changing management in 2 of 10 (20%). CT promoted 10 of 100 patients to the interval appendectomy pathway with no failures in delayed operative management. CT rarely changes management in patients highly suspicious for appendicitis, but may have a role in selecting patients for interval appendectomy. CT frequently changes management if the clinical diagnosis is indeterminate.

Postoperative urinary retention (PUR) rates vary greatly depending on the population studied. PUR leads to urinary tract instrumentation, which causes increased hospital costs and morbidity. We sought to determine our PUR rate and the risk factors that associated with it. One hundred seventy-six adult surgical inpatients were included in the study. Excluded were those receiving intraoperative catheterization, epidural anesthesia, and urologic procedures. The study population included 42 per cent spinal, 24 per cent laparoscopic abdominal, 20 per cent neck surgeries excluding the spine, and 14 per cent miscellaneous surgeries. Patient bladder volumes were determined using ultrasound scanning at three different intervals: a postvoid residual just before transfer to the operating suite, immediately on arrival in the recovery unit, and then immediately before transfer to the ward. Our overall rate of PUR was 5.7 per cent (10 of 176), defined as the need for catheterization during the postoperative hospitalization. Associated with PUR were advanced age (P = 0.0292) and postoperative bladder volume (P = 0.0246). Preoperative bladder volume, intraoperative fluid, and operative time did not reach statistical significance as being predictive of urinary retention. Our data suggest that PUR is associated with increased bladder volumes on arrival to the recovery room. A prospective study to determine whether identification of patients at risk will lead to decreased incidence of urinary tract infection is warranted.

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

A nasogastric tube (NGT) is commonly used in the postoperative period after esophagectomy for decompression of the gastric conduit. The aim of this study was to evaluate the safety of a minimally invasive esophagectomy without the use of NGT decompression. We performed a retrospective review of 124 patients who underwent minimally invasive esophagectomy. Ninety-eight patients had an NGT placed for postoperative decompression and 26 patients did not. The main outcome measure was postoperative complications in regard to the gastric conduit and esophageal anastomosis. There were 96 males with a mean age of 65 ± 11 years. Three (3%) of 98 patients with operative NGT placement developed postoperative complications directly related to the NGT, which included perforation of the gastric conduit (n = 1) and perforation of the anastomosis (n = 2). In the 26 patients without operative NGT decompression, one patient (3.8%) had distention of the gastric conduit requiring placement of a NGT under fluoroscopic guidance on postoperative Day 1. There was no significant difference in the leak rate between the groups with NGT decompression compared with the group without NGT decompression (9.2 vs 7.7%, respectively). In conclusion, the use of NGT decompression during minimally invasive esophagectomy can be safely omitted. In cases with postoperative gastric conduit distention, an NGT can be safely placed under fluoroscopic guidance.

Studies have shown conflicting data with regard to the volume and outcome relationship for gastrectomy. Using the University HealthSystem Consortium national database, we examined the influence of the hospital's volume of gastrectomy on outcomes at academic centers between 2004 and 2008. Outcome measures, including length of stay, 30-day readmission, morbidity, and in-hospital mortality, were compared among high- (13 or greater), medium- (6 to 12), and low-volume (five or less) hospitals. There were 10 high- (n = 593 cases), 36 medium- (n = 1076 cases), and 75 low-volume (n = 500 cases) hospitals. There were no significant differences between high- and low-volume hospitals with regard to length of stay, overall complications, 30-day readmission rate, and in-hospital mortality (2.4 vs 4.4%, respectively, P = 0.06). Despite the small number of gastrectomies performed at the low-volume hospitals, these same hospitals performed a large number of other types of gastric surgery such as gastric bypass for the treatment of morbid obesity (102 cases/year). Within the context of academic medical centers, lower annual volume of gastrectomy for neoplasm is not a predictor of poor outcomes which may be explained by the gastric operative experience derived from other types of gastric surgery.

The use of MRI in preoperative staging of breast cancer has escalated recently. Breast MRI has greater sensitivity than mammography, ultrasound, and clinical examination in cancer detection. Because of its variable specificity, however, there has been concern that increased MRI use will result in increased rates of mastectomy for early-stage breast cancer. We postulated that mastectomy rates are not affected by trends in MRI use. We performed a retrospective analysis of imaging tests ordered by surgeons at our breast center from 2003 to 2007. We also reviewed all breast cancer cases reported to the National Cancer Database from our institution during the same time period and categorized them as having been treated with mastectomy or breast-conserving surgery. From 2003 to 2007, the number of breast MRIs ordered annually by surgeons increased from 68 to 358. The rate of MRI use increased from 4.1 per every 100 patients seen to 5.7 and from 1.6 per every 100 new patients seen to 2.9. The percentage of women undergoing mastectomy for breast cancer remained unchanged during this 5-year interval. Therefore, although MRI use in breast cancer staging and surveillance has increased, mastectomy rates have not.

The integrity of a low pelvic anastomosis is often studied radiographically before takedown of a diverting ileostomy. The aim of this study is to determine the impact of routine water-soluble enema studies (WSE) in our patient population with low pelvic anastomosis. We retrospectively reviewed the operative database for a county teaching hospital from 1998 to 2008. All patients with low pelvic anastomosis (ultralow colorectal, coloanal, and ileoanal pouch anastomosis) with diverting ileostomy who underwent subsequent takedown were identified. Fifty patients met inclusion criteria. Thirty-eight patients were evaluated by WSE and 12 were not. Twenty-five patients (66%) were noted to have normal WSE studies before ostomy takedown. Thirteen patients (26%) were noted to have abnormalities on WSE. Two stenoses were clinically significant. Water-soluble enema study was 100 per cent sensitive and 69 per cent specific for detecting significant pathology. Digital rectal examination (DRE), colonoscopy, and flexible sigmoidoscopy were also 100 per cent sensitive in detecting substantial pathology. Routine use of WSE failed to demonstrate a significant impact on patients with low pelvic anastomosis undergoing ileostomy takedown. Routine DRE and rigid proctoscopy can be used to evaluate low pelvic anastomosis. WSE can be used selectively on patients with abnormal findings.

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

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

Pancreatic fistula is a major cause of morbidity after distal pancreatic resection. When resections are performed with linear stapling devices, the use of bioabsorbable staple line reinforcement has been suggested to decrease the rate of pancreatic fistula. Our objective was to investigate the incidence of pancreatic fistula when using the Gore Seamguard® staple line reinforcement in stapled distal pancreatic resections. A retrospective review of 30 consecutive patients with stapled distal pancreatectomy was conducted. A broad definition of pancreatic fistula was used. Clinicopathologic factors and outcomes were compared between groups. Pancreatic fistula was diagnosed in 11 of 15 patients (73%) and three of 15 patients (20%) in the Seamguard® and non-Seamguard® groups, respectively (P = 0.002). Pancreatic parenchymal transection at the neck of the gland was associated with pancreatic fistula, whereas laparoscopic procedures, splenic preservation, or additional organ resection were not. On multivariate analysis, the association between Seamguard® use and pancreatic fistula was significant (P = 0.005). In conclusion, after introduction of the Gore Seamguard® bioabsorbable staple line reinforcement, we experienced a significant increase in the rate of pancreatic fistula. This experience raises concern about the efficacy of this device in limiting pancreatic fistula after stapled distal pancreatic resection.

In contrast to adult colonic intussusception in which malignancy is the dominant cause, small bowel intussusceptions are mostly benign. Although surgery is the accepted standard treatment, its necessity in small bowel intussusceptions identified by CT scan is unknown. Twenty-three patients from 2005 to 2008 (16 males; median age, 44 years) with acute abdominal pain and CT-proven small bowel intussusception were studied. Factors associated with the necessity for surgery were determined. Among 11 patients who were managed operatively, surgery was deemed unnecessary in two patients based on negative explorations. Follow up in 10 of 12 patients managed nonoperatively was not associated with any recurrence of intussusception or malignancy (median follow up, 14 months). The only predictor of the need for surgery was CT evidence of small bowel obstruction and/or a radiologically identified lead point, which was present in 7 of 9 (78%) patients having a necessary operation and absent in 12 of 14 (86%) with no indication for surgery (P = 0.008). All small bowel intussusceptions found on CT scan in patients with acute abdominal pain do not require operative management. CT findings of small bowel obstruction and/or presence of a lead point are indications for surgery.

We report on 43 groin herniorrhaphy operations, 18 in 18 patients with documented cirrhosis and 25 in 24 patients after liver transplantation (LT), over a 10-year period at UCLA. Average follow up was 33 months. Most patients were males (84%) with reducible inguinal hernias (70%). Child's class of cirrhotic patients was B in 66 per cent and A and C in 17 per cent each; 7 patients (39%) went on to LT. Compared with post-LT patients, patients with cirrhosis had significantly lower platelets and significantly higher bilirubin, international normalized ratio, and Model for End-stage Liver Disease scores. Mesh was used in 33 per cent of the cirrhotic group and 48 per cent of the LT group. There were four minor wound complications but no deaths, major complications, infections, or ascitic leaks in either group. Two hernias recurred in the cirrhosis group (11%) and none after LT. We conclude that with proper patient selection, groin herniorrhaphy with or without mesh is a safe and durable procedure in patients with cirrhosis and after LT. This is the first large series of groin herniorrhaphy after LT.

The purpose of this study was to identify the utility of thoracic computed tomography (TCT) in blunt trauma patients with a normal admission chest radiograph (CXR). A retrospective study was performed of 200 consecutive blunt trauma patients who received both CXR and TCT. One hundred and forty-three patients had a normal screening CXR; 36 of these patients (25%) had an abnormal TCT. TCT changed the management in only nine of these patients (6%): two required serial CXR for occult pneumothorax, four received additional imaging of the spine, and three were admitted to a monitored bed. Fifty-seven patients had an abnormal initial CXR. Of these, 41 (81%) had an abnormal TCT. TCT changed management in 21 (37%) of these patients: two aortic injuries identified, 12 aortic injuries excluded, two chest tubes placed, one patient taken to the Operating Room, and four patients required further diagnostic evaluation. TCT was significantly more likely to alter management in patients with an abnormal admission CXR (6% vs 37%, P < 0.001). TCT is of limited utility in patients with a normal admission CXR. A diagnostic strategy of obtaining TCT only in patients with abnormal CXR or high-risk mechanism of injury can result in significant cost savings without adversely affecting patient outcomes.

Mammography and ultrasonography are traditional for preoperative estimation of breast cancer size; magnetic resonance imaging (MRI) is more recent but not as well studied. We compared ultrasonography, mammography, and MRI for preoperative imaging of primary breast cancer presenting as a mass in patients treated at our center over a 2-year period. Of the 61 breast cancers with all three imaging modalities performed, 52 were infiltrating ductal cancer, 5 were infiltrating lobular cancer, 2 were ductal carcinoma in situ, and 2 were other histologic types. When pathologic size was used to determine the accuracy of imaging assessments, the Pearson correlation coefficient was better for MRI (r = 0.80) than ultrasonography (r = 0.57) or mammography (r = 0.26). Mean tumor size was 2.1 cm by mammography, 1.73 cm by ultrasonography, 2.65 cm by MRI, and 2.76 cm by pathology. MRI-based tumor size was within 1 cm of pathologic size in 44 (72%) tumors, > 1 cm above pathologic size in 6 (10%) tumors, and > 1 cm below pathologic size in 11 (18%) tumors. We conclude that MRI is more accurate than either ultrasonography or mammography for assessment of the size of primary breast cancer presenting as a mass.

The treatment costs for patients in the United States with inflammatory bowel disease (IBD) exceed 1.7 billion dollars/year. Infliximab, an antibody to tumor necrosis factor-α, has been extensively used to treat IBD, with 390,000 IBD patients receiving the drug since its FDA approval in 1998. We sought to determine the impact of infliximab on population-based rates of hospitalizations and surgical care for patients with IBD in the United States. We used data from the Nationwide Inpatient Sample to analyze patterns of hospital-based treatment provided to patients with IBD between 1998 and 2005. Data from this analysis were combined with census data to calculate trends in population-based rates of treatment. Overall rates of hospitalization for patients with Crohn's disease and ulcerative colitis increased significantly between 1998 and 2005 (5.1%/year and 3.4%/year respectively, P < 0.001 for each). During the same time period there were no changes in the overall rates of surgical care. The expanding use of infliximab has not significantly impacted the use of surgical procedures for patients with either ulcerative colitis or Crohn's disease, and rates of nonsurgical hospitalizations have actually increased. Even in the era of infliximab, surgical care remains a mainstay in the treatment of IBD.

Colonic diverticular disease is responsible for over 300,000 admissions and expenditures exceeding $2.7 billion/year. There is recent evidence that rates of treatment for diverticulitis have increased in the United States over the last decade. We hypothesize that these national trends of increasing rates of hospitalizations for diverticulitis would be found in an analysis of a single-state discharge database. Data from the Office of Statewide Health Planning and Development were used to analyze treatment for diverticulitis in California from 1995 to 2006. For each hospitalization, surgical care was determined based on procedure codes for left colon resection and/or colostomy. Overall numbers of admissions for acute diverticulitis increased throughout the 12-year study period with an estimated annual percentage of change (EAPC) of 2.1 per cent (P < 0.001). Rates of admissions increased most rapidly in patients 20 to 34-years-old (EAPC = 8.6%, P < 0.001) and 35 to 49 years old (EAPC = 5.7%, P < 0.001). Elective colectomies had an EAPC of 2.1 per cent (P < 0.001), which was also most dramatic in younger age groups. Between 1995 and 2006 we found significant increases in both the rates of hospitalization for diverticulitis and rates of elective surgical treatment in California. These increases are entirely due to higher rates of care for younger patients.

Twenty-five to 30 per cent of hypotensive trauma patients require an emergent surgery, however, we have no reliable means to quickly determine that need. Our goal was to determine, via retrospective review, parameters available within minutes of arrival that predict the need for emergent surgery to control hemorrhage in hypotensive trauma patients. Inclusion criterion was initial systolic blood pressure (SBP) < 90 mm Hg in the emergency department (ED). Patients who were dead on arrival or underwent ED thoracotomy were excluded. Emergent surgery was defined as sternotomy, thoracotomy, laparotomy, or major neck vascular repair on day of admission. Potential clinical predictors were analyzed in a binary logistic regression model. Six hundred and thirty-nine hypotensive patients were identified and 193 excluded, leaving 446 with a mean age of 33 ± 19 years and Injury Severity Score of 22 ± 17. Thirty-two per cent suffered penetrating trauma, 30 per cent needed emergent surgery, and 19 per cent died. Independent predictors were: prolonged extrication (odds ratio (OR) 2.3), no loss of consciousness (OR 2.8), intubation (OR 1.7), central line placement (OR 1.7), and blood transfusion (OR 2.1, all P < 0.05). We concluded that hypotensive trauma patients without head injuries who require prolonged extrication, intubation, central venous access, and blood transfusion in the ED are more likely to need emergent surgery.

Multiple techniques are available for division of hepatic parenchyma. This is the largest United States report examining the use of the Habib 4X tissue coagulator (AngioDynamics, Queensbury, NY). The objective was to collect standard parameters associated with successful, benchmarked liver surgery outcomes using this new device, and in particular, examine the risk of margin failure. Ninety-four consecutive operations using the Habib 4X were analyzed with special attention to local failure at resection margin, blood loss/transfusion, and operative times. An institutional review board approved protocol allowed collection and analysis of demographic information and outcomes for intraoperative, perioperative, and long term follow-up. Eighteen patients had biopsy only. Thirty-one had lobar resections and 46 had wedge or segmental resections. There were 30 primary hepatic and 46 metastatic tumor diagnoses. There were a total of 33 (43%) recurrences with a mean time to recurrence of 212 days (range 15-974). Of the 27 intrahepatic recurrences, four (15%) were at the margin. The OR time ranged from 115 to 642 minutes (average 283 min). The average recorded blood loss was 427 mL; 11 patients were transfused (average 0.43 units). The Habib 4X is a safe tool to use when evaluating the parameters of blood loss, transfusion, and margin recurrence.

Abdominoperineal resection (APR) after pelvic radiation can be complicated by an increased rate of difficult to treat perineal wound complications. In an effort to improve postoperative morbidity after APR, myocutaneous flap reconstructions have been used. We review our recent experience with APR with vertical rectus abdominis myocutaneous flap reconstruction (VRAM) after preoperative pelvic radiation. A retrospective review of patients who underwent APR with VRAM reconstruction after pelvic radiation from December 2004 to July 2008 was conducted. Outcome measures included demographics, comorbidities, length of stay, wound complications, and morbidity and mortality. Fifteen patients with a mean age of 61 ± 9 years underwent APR with VRAM reconstruction. Five patients also required posterior vaginectomy with the APR. Indications for APR were rectal cancer (n = 14, 93%) and anal canal cancer (n = 1, 7%). There were no intraoperative complications. Mean estimated blood loss was 635 ± 446 mL and mean intraoperative blood transfusion requirements were 1 ± 2 units. Mean length of hospital stay was 11 ± 4 days. Six (40%) patients had minor perineal wound complications. One (7%) patient had a perineal wound infection requiring reoperation with washout and reapproximation. There was no 30-day or in-hospital mortality. All VRAM flaps remained viable through follow-up. APR with VRAM flap reconstruction after preoperative pelvic radiation can be performed safely with limited wound complications and no mortality.

Surgical management of infected prosthetic vascular grafts is associated with a significant risk of recurrent infection, limb loss, and mortality. Treatment options include graft excision with extra-anatomic bypass and in-line repair with prosthetic graft, vein, or artery. We hypothesized that inline reconstruction using cryopreserved arterial allografts would be associated with a lower recurrent infection rate, limb loss, and mortality than other alternatives. We reviewed all cases where adults underwent surgical management of infected prosthetic aortic, iliac, or femoral bypass grafts with cryopreserved arterial allograft at our medical center from 2001 to 2008. Cryopreserved arterial allografts were used in 21 patients. There were nearly equal number of men (n = 11, 52%) and women (n = 10, 48%). The median age was 63 years and median time since cryoartery repair was 4 years. There have been no deaths in the follow-up period. Complications (19%) included colon perforation (n = 1), lower extremity compartment syndrome (n = 1), limb ischemia (n = 1), and reinfection with pseudoaneurysm and subsequent limb amputation (n = 1). These positive findings of low morbidity and absence of mortality in high risk patients have resulted in a shift at our institution to the preferential use of cryopreserved arterial allograft with in-line reconstruction for infected prosthetic grafts.

The growing popularity of all-terrain vehicles (ATVs) has contributed to a rise in the number of injuries and fatalities nationwide. The Consumer Product Safety Commission reported 8,104 fatalities from 1982 to 2006 and over 146,600 emergency room-treated visits in 2006 with children 16 years of age and younger comprising roughly 29 per cent in both categories. To investigate the epidemiology and outcome of ATV-related injuries and to explore variables contributing to morbidity and mortality, we conducted a single-center, retrospective study of ATV-injured patients presenting to trauma emergency between 2003 and 2007 at a Level II trauma center. In summary, we witnessed an upward trend in the incidence of ATV injuries during this 5-year span. With 156 documented cases, adolescents aged 17 to 20 years represented the largest group (19.2%), whereas children 16 years of age and younger contributed to 12.8 per cent. Overall mortality rate was 0.64 per cent. Positive blood alcohol concentration was detected in 21 per cent. Individuals using protective gear were 1.4 and four times less likely to suffer loss of consciousness and Glasgow Coma Scale score 8 or less, respectively, compared with those without protection. Abrasions, concussions, fractures, and other life-threatening solid organ injuries were documented in virtually every organ system. With such poor outcomes, we conclude that riding an ATV is an inherently dangerous activity. To minimize the burden of injury, riders are encouraged to develop competency through training courses, compliance with safety precautions, and modification of high-risk behaviors.

Hypotension is a trauma activation criterion validated by multiple studies. However, field systolic blood pressures (SBP) are still met with skepticism. How significant is the role of prehospital (PH) and emergency department (ED) SBP in the patient's overall condition? A review of the trauma registry over a 5-year period was conducted. PH SBPs were stratified into four categories: severe (SBP 80 mmHg or less), moderate (81-100 mmHg), mild hypotension (101-120 mmHg), and normotension (greater than 120 mmHg). These four groups were further subcategorized into the patients who were hypotensive, SBP 90 mmHg or less in the ED, versus those that were not (SBP greater than 90 mmHg). Data for 6964 patients were analyzed. Patients with PH SBP of 80 mmHg or less compared with patients who had PH SBP of greater than 80 mmHg had higher mortality (OR, 9; 95% CI, 6.45-12.84). Patients with both PH SBP 80 mmHg or less and ED SBP 90 mmHg or less had the highest risk of mortality (50%) and highest need for emergent operative intervention (54%). PH and ED hypotension is a strong predictor of in-hospital mortality and need for emergent surgical intervention in trauma patients. Field or ED blood pressures should serve as a significant marker of the patient's condition.

Laparoscopic techniques in colon surgery reduce postoperative pain, length of hospital stay, and 30-day morbidity when compared with open surgery. The objective of this study was to determine the feasibility of a laparoscopic colectomy in patients who have previously undergone abdominal surgery. We performed a retrospective, single-institution review of laparoscopic colorectal procedures for benign or malignant pathology between October 2002 and September 2008. Our analysis included 55 patients who previously had laparoscopic, open, or a combination of procedures and subsequently underwent laparoscopic colorectal surgery. We observed a 14.5 per cent conversion rate (n = 8). Of the patients who had previous open procedures (n = 48 [87.3%]), the conversion rate was 16.7 per cent. Only one patient (12.5%) who had a history of only laparoscopic surgery required conversion. The highest conversion rate in our study was from patients who underwent a left colectomy (60%, n = 3/5), which was the only statistically significant factor found for conversion. Since the emergence of laparoscopy, use in colon and rectal surgery nationwide has been poor as a result of multiple factors, including a frequent history of abdominal surgery. Our experience shows that laparoscopic colorectal surgery in patients with prior intra-abdominal surgery can be completed with an acceptable conversion rate.

The purpose of this study was to review the incidence of extreme thrombocytosis (ExT) (platelet count 1,000,000/μL or greater) in trauma patients and to examine the role of antiplatelet agents in its treatment. The Los Angeles County Medical Center trauma registry was used to obtain injury demographics, medications, and daily platelet counts for injured patients 16 years of age or older admitted between July 2005 and February 2008. Of 6,985 total trauma patients admitted during the study period, 95 developed ExT (1.4%). Average age was 29 years (range, 16-63 years), 89 per cent were male, 44 per cent had penetrating trauma, and mean Injury Severity Score was 24 (range, 1-57). Of the 95 patients with ExT, 41 were treated with aspirin (43%) and 54 were not (57%). The two groups did not differ with regard to basic demographics, injury patterns, vitals on admission, or splenectomy rate (34 vs 20%, P = 0.13). After adjusting for maximum platelet counts and duration of ExT, there was no difference between the treated and untreated groups in terms of mortality, complications, and intensive care unit or hospital lengths of stay. The incidence of ExT is approximately 1.4 per cent in trauma patients. Antiplatelet therapy does not affect ExT patient outcome. Further prospective studies are warranted.

Pancreatic neuroendocrine tumors (pNETs) are an uncommon pancreatic neoplasm. We reviewed the presentation, management, and outcome of patients with pNETs treated at a single center by a multidisciplinary approach between 2004 and 2008. Over this time period, 154 patients with carcinoid and neuroendocrine tumors were treated, which included 46 patients (30% of total) with pNETs. The most common presentations included abdominal pain (20 of 46 [43%]), systemic symptoms such as hypoglycemia (15 of 46 [33%]), and incidental mass (7 of 46 [15%]). Fourteen patients had functional tumors. At the time of diagnosis, 22 patients (48%) presented without metastases and 24 (52%) had metastatic disease. Median follow up for the entire group was 42 months. All patients with nonmetastatic pNET underwent pancreatic resection with 95 per cent postoperative survival. Overall survival in this group at 3 years was 86 per cent and disease-free survival was 81 per cent. In patients presenting with metastatic pNET, multiple treatment modalities were used, including liver resection or ablation (n = 15), hepatic chemoembolization (n = 17), pancreatic resection (n = 12), and systemic treatments (n = 7). Three-year survival was 70 per cent. Pancreatic resection results in greater than 80 per cent 3-year survival in nonmetastatic pNET. In patients presenting with metastatic pNET, excellent survival rates are also achievable using a multidisciplinary multimodal approach.