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Because work hour restrictions and technological developments such as staplers change the surgical landscape, efficient resident training methods are necessary to ensure surgical quality. This study evaluates efficacy of a porcine skills laboratory for teaching surgery residents to perform handsewn intestinal anastomoses based on a validated subjective tool and novel objective measurements. We hypothesized that resident performance would improve postintervention; junior residents would improve more than the seniors would. This prospective study was completed over a period of four months in 2015. Participants performed standardized two-layer, handsewn, end-to-end small intestine anastomosis in a live porcine model before (pretest) and after (posttest) an educational intervention. The intervention consisted of an instructional module and skills laboratory teaching session by attending surgeons. Participants were evaluated based on objective measurements of the anastomosis and blinded video evaluations using objective structured assessment of technical skills. Twenty-eight residents in a six-year general surgery program started and completed the study. The objective structured assessment of technical skills ratings demonstrated that the whole resident cohort had statistically significant improvement in pre- to posttest scores, 11.16 to 24.59 ( P < 0.001). Junior and senior residents improved independently, 9.59 versus 22.53 ( P < 0.001) and 13.59 versus 27.77 ( P < 0.001), respectively. Finally, the cohort significantly improved in number of full-thickness Lembert sutures (2.36 vs 0.93, P = 0.001) and time to completion (31.28 vs 28.2 minutes, P = 0.046). Anastomotic leak pressure, anastomotic narrowing, and anastomotic tensile strength all trended toward improvement. A structured educational intervention, teaching intestinal anastomosis in a live porcine model produced significant improvement in residents' technical skills.

Transanal excision of rectal tumors may be performed using the Ferguson Operating Anoscope (FOA). This retrospective case series evaluates the effectiveness of FOA for the excision of selected benign and malignant rectal tumors. The office records of 97 patients with rectal tumors who underwent FOA transanal excision by a single surgeon from 1999 through 2009 were reviewed. In the 97 patients evaluated, 99 FOA transanal excisions were performed for 39 adenocarcinomas, 55 benign tumors, and five carcinoid tumors. The tumors were 0.5 to 13.5 cm in diameter and located an average of 6.9 cm (range, 1 to 15 cm) from the anal verge. Ninety-one per cent of cases were performed as an outpatient. Postoperative complications occurred in 14 per cent with transient effects on continence in 2 per cent and a mean blood loss of 66 mL. The recurrence rate for favorable T1 rectal cancers was 4.3 per cent and for adenomas was 5.9 per cent. In early follow up of adenomas and favorable T1 carcinomas, FOA transanal excision has similar application, morbidity, and recurrence rates as reported for transanal endoscopic microsurgery for rectal tumors within 15 cm from the anal verge. FOA may be considered a useful option for the minimally invasive treatment of rectal tumors.

Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly responsible for infections in hospitalized patients. Patients colonized with MRSA appear to be at higher risk for subsequent MRSA infections than those who are not colonized. In this study, we determined MRSA colonization status of trauma patients at hospital admission and compared the incidence of subsequent MRSA infections between MRSA colonized and noncolonized patients. Collected data were entered into databases at a single, Level I trauma center over a 13-month period. Three hundred fifty-five adult trauma patients were screened for MRSA on admission to the trauma intensive care unit. The patients were categorized into two groups, those colonized with MRSA at admission and those who were not. Thirty-six of 355 patients (10.1%) were colonized. Of the 319 patients not colonized, 21 (6.6%) developed MRSA infections. Twelve of 36 (33.3%) colonized patients developed MRSA infections (P < 0.001). No differences in types of MRSA infections were found between the two groups. Colonized patients who developed MRSA infections had higher death rates, 22.2 versus 5.0 per cent (P < 0.001). Patients colonized with MRSA on admission may be at higher risk for developing MRSA infections during hospitalization. MRSA screening protocols should be used to identify these at-risk patients.

With the development of expertise in image guidance for breast surgery, many surgeons now perform preoperative wire localization themselves. Use of a single wire versus multiple wires to bracket a radiographic breast abnormality has previously been described, although benefits of this technique based on clinical outcomes such as margin status, tissue volume removed, and re-excision rates have not been established. This study is a retrospective analysis of wire-localized breast biopsies performed by 14 surgeons over 29 months; stereotactic and ultrasound guidance were used. During this time, 489 wire localizations were done, of which 159 used multiple wires. Two hundred eleven of these biopsies were done for malignant disease, 86 using multiple wires. After controlling for tumor node metastases stage, single and multiple wire placements were compared using endpoints of margin status, need for re-excision, and total volume of tissue removed. Neither margin status nor re-excision was related to the number of wires placed. However, the number of wires placed was significantly related to the total volume of tissue removed. Use of more than one localizing wire was associated with greater volume of tissue removal (measured in centimeters cubed) in benign disease (46 vs 25, P < 0.001), equivalent volumes in stage 0 disease (73 vs 67), less volume in stage 1 disease (113 vs 164), and less volume in stages 2 through 4 (158 vs 207, P = 0.03). Outcomes based on surgeon case volume during the study period demonstrated that low- (1-40), medium- (41-80), and high-volume (>80) surgeons did not differ in the type or stage of breast pathology treated. Surgeons with high case volumes were more likely to place multiple localizing wires (P < 0.001) and were more likely to do a breast-conserving procedure if re-excision was performed (P < 0.018). Surgeons with low case volumes were more likely to perform a re-excision (P < 0.025). Surgeon experience has a positive impact on quality outcome measures such as performance of a definitive procedure at the time of initial surgery and use of breast-conserving procedures at the time of re-excision. Multiple wire localization can be used to significantly reduce the volume of breast tissue removed in malignant disease without sacrificing margin status or increasing the need for future re-excision.

The Accreditation Council for Graduate Medical Education (ACGME) requires all programs to limit resident work hours to 80 hours per week with some programs allotted an extra 10 per cent for specific educational purposes. The purpose of this study was to evaluate data reflecting changes in resident schedules made in 2002-2003 to be compliant with ACGME requirements without compromising patient care or resident education. Surgery residents originally completed a work-hour survey in May 2002. The survey contained 14 daily time sheets. Residents were asked to document how their time was spent between 14 different categories delineating in-house and out-of-house hours. Changes were made to resident schedules in order to become compliant with the new regulations. After making changes in the schedule, two more surveys were completed and evaluated, once in May 2003 and again in November 2003. Final analyses compared results from May 2002 to November 2003. Surveys were distributed to 30 residents in May 2002. Twenty-two residents completed the survey with 16 surveys eligible for analysis following exclusion of abnormal rotations (i.e., research and vacation). Eighty-eight per cent of junior residents (PGY 1, 2, and 3), 50 per cent of senior residents (PGY 4-5), and 33 per cent of chief residents (PGY 6) worked more than 88 hours per week. In November 2003, surveys were sent to 32 residents. Twenty-four residents who were on our normal call schedule completed the survey. Fourteen per cent of junior residents, 33 per cent of senior residents, and 0 per cent of chief residents worked more than 88 hours per week. By making the changes described, we have substantially reduced the number of resident work-hours while maintaining our academic and patient care missions.

Lower extremity fractures (LEFx) and pelvic fractures (PFx) are believed to increase the risk of lower extremity deep vein thrombosis (LEDVT). We studied trauma patients at high risk for LEDVT to determine whether an increased incidence of LEDVT was associated with LEFx and/or PFx. From January 1995 through December 1997 4163 trauma patients were admitted to our Level I trauma center. One thousand ninety-three patients at high risk for LEDVT were screened with serial lower extremity venous duplex ultrasound. Their medical records were retrospectively reviewed for demographics, mechanism of injury, and fracture data. The occurrence of LEDVT, pulmonary embolus, and LEDVT prophylaxis and treatment were noted. The incidence of LEDVT in the fracture group (Fx) was compared with that in the nonfracture group (NFx) using chi-square analysis and logistic regression. Statistical significance was set at < or = 0.05. Complete data were available for 1059 of 1093 patients. Five hundred sixty-nine (53.73%) patients had PFx and/or LEFx, 151 (14.26%) patients had PFx only, 317 (29.3%) patients had LEFx only, and 101 (9.54%) patients had both PFx and LEFx. Four hundred ninety (46.27%) patients had NFx. In 1059 patients LEDVT was detected in 125 (11.8%). Sixty-three patients in the Fx groups developed LEDVT (50.4%): 19 (15.2%) PFx patients, 15 (12.0%) PFx/LEFx patients, and 29 (23.2%) LEFx patients. Sixty-two (49.6%) NFx patients developed LEDVT. LEDVT incidence was not significantly different between the Fx and NFx groups or among the PFx, LEFx, and PFx/LEFx groups (P = 0.317). Nine patients developed pulmonary embolism: four NFx patients, two LEFx patients, two PFx patients, and one PFx/LEFx patient. Significant predictors of LEDVT were age and hospital length of stay. Mean age in patients with LEDVT was 47.58 years and in patients without LEDVT it was 40.89 years (P < 0.001). Mean hospital length of stay in patients with LEDVT was 29.81 days and in patients without LEDVT it was 16.84 days. The power of this study to detect differences representing medium effect sizes was greater than 90 per cent. We conclude that LEFx and/or PFx was not associated with an increased incidence of LEDVT in trauma patients at high risk for LEDVT. Lower extremity venous duplex ultrasound needs to be performed in both Fx and NFx groups to detect LEDVTs.

Stereotactic core needle biopsy (SCNB) is a sensitive and specific indicator of breast pathology. Commonly the first biopsy core is taken from the center of the lesion in question. Multiple cores are then taken from points peripheral to the central core. The sensitivity and specificity of the central core to diagnose breast disease is unclear. We compared the pathology of the central core biopsy with that of the remaining cores in a prospective study to determine the sensitivity and specificity of the central core to diagnose breast disease. All patients undergoing SCNB for breast lesions in a single surgical office during a 7-month period were eligible for inclusion. One hundred thirty-three patients with first cores from 145 biopsy sites were included. The histologic diagnosis from 117 (81%) of the first cores from these 145 biopsy sites were representative of their respective samples as a whole. Seventy-seven (53%) of the first cores were in complete agreement with the final histologic diagnosis whereas 40 (28%) had minor differences with the histologic diagnosis that had little or no clinical significance. Twenty-eight (19%) central core samples did not agree with the final pathologic diagnosis. Seven of these 28 patients each had a final diagnosis of cancer missed by the central core biopsy. The first core sample had a sensitivity for cancer detection of 79 per cent and specificity 100 per cent. SCNB remains a sensitive and specific identifier of breast pathology. When mammographic evidence of calcifications was the primary indication for SCNB (n = 75) calcification was present in the central core in 51 (68%). In these 51 patients the central core biopsy was in agreement with the final histologic diagnosis in 46 (90%) specimens. Histologic review of the first core sample alone lends no increased benefits and in fact misrepresents the pathology present in a significant number of patients. When analyzed as an independent predictor of breast pathology the first core is a more sensitive indicator than subsequent individual cores, but the most accurate predictor of pathology is examination of the entire group of core samples. This study confirms the need for acquisition of multiple cores from each lesion in question.

The purpose of this study was to determine the effectiveness of the Thow long intestinal tube (LIT) for prevention of postoperative adhesive small bowel obstruction (ASBO) and to compare the Thow tube with other LITs. The charts of all patients who had placement of a Thow tube between January 1986 and November 1998 were reviewed. Thirty-four patients ranging in age from 9 to 86 years (mean 57.9) were included in the study. Twenty-five were contacted by phone for long-term follow-up. Twenty-nine patients had undergone previous abdominal surgery, and in 11 of 29 the previous surgery was for ASBO. Indications for surgery and Thow tube placement included: bowel obstruction (25), perforated viscus (five), carcinomatosis (two), colitis (one), and atonic bowel (one). Review of the operative notes revealed no difficulty in advancing the Thow tube in 32 of 34 patients (94%). Thow tube-related complications occurred in nine patients (25%). All complications were associated with the gastrostomy site, and only one patient required surgery for the complication. Two (5.9%) patients developed recurrent obstruction during a mean follow-up of 52 months. In one patient the obstruction was caused by adhesions and in another it was the result of an intra-abdominal abscess. Of 23 patients treated for ASBO at the time of Thow tube placement no patient (0%) developed recurrent ASBO during the follow-up period (total 110.5 patient-years). This study along with a review of the literature suggests that LITs decrease the risk of recurrent ASBO. The Thow tube, however, is easily placed and is associated with fewer and less severe complications than other LITs.

We evaluated the efficacy of subatmospheric pressure and hyperbaric oxygen (HBO) as adjuncts in the treatment of hypoxic full-thickness wounds in a rabbit model. We hypothesized that subatmospheric pressure and HBO independently are effective in improving wound healing in the ischemic wound model and that when they are used in combination there is an increased positive effect on wound healing. Using a standard ischemic wound model four full-thickness wounds were created on each ear of 41 male New Zealand white rabbits (N = 82 ears). On each rabbit one ear was dressed with the vacuum-assisted closure (VAC) device and connected to suction; the other was dressed identically without the suction and suction tubing. Twenty rabbits were treated with HBO daily for 10 days at 2.0 atmospheres absolute for 90 minutes plus descent and ascent times. Necropsy on all rabbits was performed on postoperative day 10. Four ischemic wound treatment groups were evaluated: Group 1 (N = 21) VAC dressing alone; Group 2 (N = 20) VAC dressing plus HBO; Group 3 (N = 21) VAC dressing to suction alone; and Group 4 (N = 20) VAC dressing to suction and HBO. Using light microscopy a veterinary pathologist blinded to treatment groups quantified peak granulation tissue, granulation tissue gap, and epithelialization tissue gap. Data were analyzed by analysis of variance with significance indicated by P < 0.05. Statistical significance was found in a comparison of VAC dressing to suction and VAC dressing alone for peak granulation tissue and granulation tissue gap both with and without use of HBO. VAC device use appears to increase the rate of healing in a rabbit ischemic wound model. HBO therapy did not significantly affect the rate of healing in this model.

Hyoid bone fractures secondary to blunt trauma other than strangulation are rare (ML Bagnoli et al., J Oral Maxillofac Surg 1988; 46: 326-8), accounting for only 0.002 per cent of all fractures. The world literature reports only 21 cases. Surgical intervention involves airway management, treatment of associated pharyngeal perforations, and management of painful symptomatology. The importance of hyoid fracture, however, rests not with the rarity of it, but with the lethal potential of missed diagnosis. We submit three cases with varying presentations and management strategies. All three of our cases incurred injury by blunt trauma to the anterior neck. Two patients required emergent surgical airway after unsuccessful attempts at endotracheal intubation. One patient presented without respiratory distress and was managed conservatively. After fracture, the occult compressive forces of hematoma formation and soft tissue swelling may compromise airway patency. It is our clinical observation that hypoxia develops rapidly and without warning, leading to cardiorespiratory collapse. With endotracheal intubation prohibited by obstruction, a surgical airway must be established and maintained. Recognition of subtle clinical and physical findings are critical to the diagnosis of laryngotracheal complex injuries and may be life-saving in many instances. To ensure a positive outcome, a strong degree of suspicion based on mechanism of injury is mandated.

When thoracic aortic rupture is suspected, a 45-degree reverse Trendelenburg (RT) anteroposterior (AP) chest radiograph should place the mediastinal structures in a more appropriate position and allow a more accurate evaluation than a supine AP radiograph. One hundred ninety-one consecutive hemodynamically stable adult patients with major blunt thoracic trauma were initially evaluated for mediastinal abnormalities associated with aortic disruption by both supine AP chest radiograph and an AP chest radiograph with the patient in 45-degree RT position. One hundred four patients underwent contrast aortography based on mediastinal abnormalities detected on the supine AP chest radiograph. Twenty of these patients had abnormal aortograms demonstrating traumatic aortic disruption confirmed at surgery. Supine and RT chest radiographs were retrospectively compared in a blinded fashion to evaluate their specificity and positive predictive value for detection of traumatic thoracic aortic rupture. If RT chest radiographic findings had been used to determine the need for further assessment, 29 angiograms (26%) would have been eliminated, specificity would have increased from 52 per cent to 69 per cent, and positive predictive value would have increased from 19 per cent to 27 per cent. Both supine and RT chest radiographs demonstrated mediastinal widening in all 20 patients with abnormal aortograms, with no missed thoracic aortic disruptions (100% sensitivity). This study indicated that the RT chest radiograph may be used instead of the standard supine radiograph as the initial screen for mediastinal evaluation, maintaining a high sensitivity and eliminating the cost and morbidity of many unnecessary aortograms.

Primary aortoenteric fistulae (AEFs) are extremely rare vascular entities, with fewer than 250 cases reported in the world medical literature as of 1996. Incidence is less than 1 per cent, with a mortality ranging from 33 to 85 per cent. Atherosclerosis remains the most common etiology, accounting for more than two-thirds of the cases reported. Other etiologies include carcinoma, ulcers, gallstones, diverticulitis, appendicitis, and foreign bodies. Early diagnosis is crucial for survival and mandates recognition of the typical "herald bleed." Additional findings on initial presentation frequently include flank pain, abdominal pain, hematemesis, melena, and an abdominal mass. More than 80 per cent of primary AEFs involve the duodenum, with the overwhelming majority located in the third or fourth portion. Successful management of primary AEF requires a high index of suspicion for diagnosis and prompt surgical intervention for survival.

The endovascular treatment of peripheral arterial occlusive disease has historically been performed by interventional radiologists and cardiologists. With additional training in endovascular techniques, surgeons become uniquely suited to manage arterial lesions with both endovascular and conventional surgical techniques. Over a 14-month period, 13 patients underwent combination endovascular and open reconstruction on limbs with peripheral arterial occlusive disease. There were 10 males and 3 females. The mean age was 66 years. All procedures were performed in the operating room by surgery residents under the direct supervision of vascular surgeons. After intraoperative angiography, 26 arterial lesions underwent percutaneous transluminal angioplasty (aorta, 1; common iliac, 14; external iliac, 10; superficial femoral, 1). Twenty-five of 26 lesions were further treated with intraluminal stent placement, the lone exception being a case of superficial femoral artery angioplasty. Concomitant open reconstruction was performed on all limbs, 14 as outflow and 1 as inflow. There were two cases of procedural morbidity and one perioperative death secondary to myocardial infarction. There were no wound-related complications. The mean ankle-brachial index of the affected lower extremity improved from 0.41 (+/- 0.15) to 0.74 (+/- 0.14) at 30 days. Mean follow-up was 8 months (range, 2-14). Based on our early experience, simultaneous combination endovascular and open reconstruction of multisegment arterial occlusive disease can be performed safely and efficiently by surgeons.

Published data is controversial as to the ability of preoperative localization studies (PLS) to enhance the outcome of initial cervical exploration in patients with primary hyperparathyroidism (PHPT). One surgeon's experience was reviewed to compare surgical success, operative time, and morbidity of initial cervical exploration for PHPT in patients who had undergone PLS versus those who had not. From August 1991 to September 1997, 95 patients who had not undergone prior central cervical exploration presented for surgical management of PHPT. Sixty-seven patients underwent initial cervical exploration without any PLS having been performed (Group A). Twenty-eight patients underwent PLS, either alone or in combination, before surgical intervention (Group B). Analysis of intergroup variability was conducted upon the data available using a two-tailed t test for independent samples. In addition, the sensitivities and positive predictive values of the PLS were calculated using study reports and operative and histologic findings. There was no statistically significant difference in surgical success between those patients who had PLS and those that did not undergo PLS. Sixty-four of 67 patients (95.5%) not having PLS were cured with initial surgery, while 27 of 28 patients (96.4%) who had PLS were surgically cured. Mean postoperative calcium and intact parathormone levels were similar between the two groups, and the mean operative time did not differ. Permanent hypocalcemia occurred in one patient, and five patients had transient hoarseness. Thirty-six total PLS were obtained at an average cost of $752.68/patient, and seven patients underwent multiple tests. Overall, sestamibi scan had the highest positive predictive value (81%). For adenomatous disease alone, sestamibi scan was the most sensitive (83%). Our study shows that for matched groups limited to age, sex, and clinical diagnosis, the use of PLS did not shorten operative time, decrease complication frequency, nor alter the success of the operation as measured by postoperative calcium and parathormone levels. Therefore, routine use of preoperative localization studies before initial cervical exploration for PHPT cannot be recommended.

The purpose of this review is to present a 4-year experience with the vacuum pack technique of temporary abdominal closure. From April 1992 to December 1996, 171 vacuum packs were performed on 93 patients. Eighty-seven vacuum packs were performed on 38 general surgical patients, and 84 vacuum packs were performed on 55 trauma patients. Overall hospital mortality was 32 per cent. Methods of achieving permanent wound closure varied in 73 patients. Four patients (4.3%) developed enterocutaneous fistulae; four patients developed intra-abdominal abscesses (4.3%). There were no eviscerations. Management of the complicated intra-abdominal process is discussed: 1) the decision to manage the abdomen in an open fashion; 2) which method of temporary closure to use; 3) subsequent explorations; 4) when the abdomen should be closed; 5) which type of closure to use; and 6) when the abdominal wall should be revised (herniorrhaphy). The vacuum pack is the method of choice for open abdomen management and temporary abdominal closure at our institution. With careful subsequent management, good patient outcome can be achieved.

The purpose of this review is to investigate the utility of autotransfusion in trauma patients in the past 3 years. A retrospective review was conducted of the charts for whom the Haemonetics Cell Saver autotransfusion device (Haemonetics Corp., Natick, MA) was utilized between January 1, 1993, and December 31, 1995. The estimated blood loss and quantity of blood transfused were noted for abdominal trauma patients. Costs of autotransfusion were then compared to estimated blood bank costs for this group. The Haemonetics Cell Saver autotransfusion device was requested for 592 cases from January 1, 1993, to December 31, 1995. Nonorthopedic trauma cases comprised 25 per cent of all autotransfusion cases. One hundred twenty-six patients had isolated abdominal trauma and had a mean estimated blood loss of 4864 +/- 6070 cc. The average volume of intraoperatively salvaged autologous blood transfused (autotransfusion) per patient was 1547 +/- 2359 cc, or a bank blood equivalent of 6.9 units of packed red blood cells. The total cost of autotransfusion in these patients was $63,252.00. Had bank blood been used instead of salvaged autologous blood, the cost would have been $114,523.00; thus, autotransfusion resulted in a savings of $51,271.00. The use of salvaged autologous blood comprised 45 per cent of total blood transfused. On a case-by-case basis, 75 per cent of cases were cost-effective compared to blood bank costs for an equivalent transfusion. Transfusion of intraoperatively salvaged autologous blood (autotransfusion) is a cost-effective, efficient way to provide blood products to operative trauma patients.

Undetected lower-extremity deep-vein thrombosis (LEDVT) in the trauma patient can lead to significant morbidity and mortality. The purpose of this study was to: 1) evaluate the role of ultrasonography in the early detection of LEDVT in high-risk trauma patients; 2) identify prognostic indicators that predict LEDVT; and 3) evaluate the efficacy of selected inferior vena cava (IVC) filter placement in the prevention of pulmonary emboli. From October 1993 through December 1994, all adult multiple-trauma patients admitted to the Trauma Service who required prolonged bed rest (>3 days) or sustained a lower-extremity, pelvic, or spinal fracture with paralysis were prospectively studied with serial physical examinations and lower-extremity venous ultrasounds within 72 hours of admission and then weekly until discharge. Two hundred twenty-eight patients were entered into the study. Thirty-nine patients (17%) developed ultrasound evidence of LEDVT; of these, only seven (18%) were evident on physical examination. This allowed 32 patients (82%) with unsuspected LEDVT to receive earlier definitive therapy. Multivariate logistic regression analysis of LEDVT with various predictors found age, hospital length of stay, and lower-extremity trauma to be significant predictors of LEDVT (P < 0.05). Twenty-nine patients (74%) had immediate IVC filter placement upon ultrasound identification of proximal LEDVT. None of these patients developed pulmonary emboli. Ten patients (26%) with a LEDVT were treated with systemic anticoagulation alone. One of these patients sustained a fatal pulmonary embolus. In a historic control group of 234 high-risk trauma patients admitted in the 14 months prior to implementing screening ultrasounds, six patients sustained pulmonary emboli (P < 0.05). Screening ultrasounds combined with selective placement of IVC filters play an important role in reducing the morbidity and mortality associated with LEDVT in high-risk trauma patients.

The purpose of this study was to determine 1) the incidence and magnitude of elevation in admission serum amylase and lipase levels in extrapancreatic etiologies of acute abdominal pain, and 2) the test most closely associated with the diagnosis of acute pancreatitis. Serum amylase and lipase levels were obtained in 306 patients admitted for evaluation of acute abdominal pain. Patients were categorized by anatomic location of identified pathology. Logistic regression analysis was used to compare the enzyme levels between patient groups and to determine the correlation between elevation in serum amylase and lipase. Twenty-seven (13%) of 208 patients with an extrapancreatic etiology of acute abdominal pain demonstrated an elevated admission serum amylase level with a maximum value of 385 units (U)/L (normal range 30-110 U/L). Twenty-six (12.5%) of these 208 patients had an elevated admission serum lipase value with a maximum of 3685 U/L (normal range 5-208 U/L). Of 48 patients with abdominal pain resulting from acute pancreatitis, admission serum amylase ranged from 30 to 7680 U/L and lipase ranged from 5 to 90,654 U/L. Both serum amylase and lipase elevations were positively associated with a correct diagnosis of acute pancreatitis (P < 0.001) with diagnostic efficiencies of 91 and 94 per cent, respectively. A close correlation between elevation of admission serum amylase and lipase was observed (r = 0.87) in both extrapancreatic and pancreatic disease processes. Serum amylase and lipase levels may be elevated in nonpancreatic disease processes of the abdomen. Significant elevations (greater than three times upper limit of normal) in either enzyme are uncommon in these disorders. The strong correlation between elevations in the two serum enzymes in both pancreatic and extrapancreatic etiologies of abdominal pain makes them redundant measures. Serum lipase is a better test than serum amylase either to exclude or to support a diagnosis of acute pancreatitis.

Minimally invasive diagnostic techniques in evaluating patients with breast disease have been increasingly utilized and accepted by physicians and patients over recent years. The incorporation of stereotactic core needle biopsy and ultrasound-guided core needle biopsy into the office practice of evaluating patients with breast disease by our surgical faculty has been met favorably. These procedures are readily learned by surgeons. The judicious use of these procedures is evidenced by the malignancy rate of core biopsies of 16 per cent, identical to the historical rate for needle localization assisted excisional biopsy at our institution. Core breast biopsy expedites definitive diagnosis and optimizes patient convenience. Reimbursement is highly variable, and active physician participation in negotiating with payors to insure that costs are met is essential.

Mechanical ventilatory support requiring tracheal intubation may be necessary for variable lengths of time in injured patients. Criteria useful in predicting the need for prolonged tracheal intubation has not been clearly established in the trauma population. Early identification of patients requiring prolonged tracheal intubation and mechanical ventilatory support could lead to earlier tracheostomy and subsequent reductions in complications associated with prolonged endotracheal intubation. This study evaluated the ability of clinical measures of injury severity, mental status, oxygenation, and ventilation to predict the need for prolonged mechanical ventilatory support (> or = 14 days) early in the postinjury course of the adult trauma patient requiring endotracheal intubation and mechanical ventilatory support within the first 24 hours of injury. All adult trauma patients admitted to our Level I trauma center over a 4-year period between January 1990-December 1993 were evaluated. A total of 212 patients met study criteria that included intubation within the first 24 hours of injury, ventilatory support requirement > or = 72 hours, and a survival time of at least 14 days postinjury. Data pertaining to measures of injury severity (RTS, AIS, ISS), mental status (GCS), oxygenation [(A-a)O2], and ventilation (VE,EDC) were recorded for postinjury Day 1 and Day 5. There were 157 males and 55 females (age range of 16-91 years, mean 39.5 years). Mechanism of injury was blunt in 198 and penetrating in 14 patients. One hundred patients required prolonged mechanical ventilatory support. Data were analyzed by stepwise logistic regression analysis. Age and GCS values on Day 1 predicted the need for long term mechanical ventilatory support in a select group of patients, age 20 and GCS of 3 (P < 0.05). At Day 5, age, GCS, and (A-a)O2 gradient were predictive of the need for prolonged mechanical ventilatory support (P < 0.05). On Day 5, GCS of 3 predicted the need for long-term mechanic al ventilatory support regardless of age or (A-a)O2 gradient. GCS < or = 5 and (A-a)O2 > or = 150 predicted prolonged mechanical ventilatory support in young patients (age 20). At ages of 40 to 60, GCS < or = 7 and (A-a)O2 > or = 150 indicated the need for long term mechanical ventilatory support. In older patients (age > or = 80), GCS < or = 7 and (A-a)O2 gradient > or = 100 were predictive of long-term mechanical ventilatory support. Appropriate use of these clinical indicators may assist in early identification of patients requiring prolonged mechanical ventilatory support, and subsequent conversion from endotracheal intubation to tracheostomy with anticipated reduction in complications.

Temporary closure of abdominal surgical wounds is occasionally required when conditions of the abdominal wall or peritoneal cavity prevent closure or when early re-exploration is planned. The optimal temporary closure should contain and protect the contents of the peritoneal cavity from external contamination and injury; preserve the integrity of the abdominal wall; be simple to perform and maintain; provide ease of reentry; and have minimal adverse physiologic effects. Based on these criteria, a method of temporary abdominal wound closure (termed the vacuum pack) has been designed and evaluated. The operative technique includes 1) placement of a fenestrated polyethylene sheet between the abdominal viscera and anterior parietal peritoneum; 2) placement of a moist, sterile laparotomy towel over the polyethylene sheet; 3) placement of two closed suction drains over the towel; 4) placement of an adhesive backed drape over the entire wound, including a wide margin of surrounding skin; and 5) suction applied to the drains, creating a vacuum and rigid compression of the layers of closure material. This creates a tight, external seal of the adhesive backed drape and facilitates drainage of the peritoneal cavity. From April 1992-December 1993, this temporary abdominal wound closure was performed 56 times in 28 patients, ages 6-78 years, for periods of 1-11 days. The procedure was used in 17 trauma patients and 11 non-trauma patients. Indications for use included increased intra-abdominal pressure in nine, mandatory re-exploration in 10, and a combination of these indications in nine patients. Pre- and postprocedural airway and systemic blood pressures were unaffected by this closure.(ABSTRACT TRUNCATED AT 250 WORDS)

Breast cancer will affect approximately one woman in nine, and it is estimated that approximately one-third of the 500,000 new cases of cancer among American women in 1993 will be cancer of the breast. With no current method of prevention available, early detection of breast cancer by regular self and physician performed breast examination in conjunction with screening mammography is emphasized. The rate of breast cancer detection has accelerated due to the ability of mammography to identify nonpalpable breast lesions. From January 1987 to January 1992, 1,323 breast biopsies were performed at Erlanger Medical Center, with 559 of these biopsies performed on 541 patients, utilizing needle localization. Of the 559 biopsies, 92 were positive for malignancy (17%). The mean patient age at detection of malignant lesions was 55.2 years. The most common mammographic abnormality leading to biopsy was an irregular breast tissue matrix (mass or density) with 25/191 (13%) biopsies positive for malignancy. The mammographic abnormality associated with the highest malignancy rate was the presence of calcifications in association with a mass or density 16/56 (29%). The upper outer quadrant (UOQ) was the most common site of biopsy 313/559 (56.0%), and biopsies from this region had the highest incidence of malignancy 67/313 (21%). Eighty-seven of the 92 patients with biopsy-proven malignancy underwent subsequent definitive surgical treatment. Tumor size did not correlate with node negative status, but evidence of microscopic invasion did. Preinvasive (in-situ) lesions were present in 23/92 biopsies (25%). There was no axillary involvement associated with in-situ carcinomas.

Laparoscopic cholecystectomy has emerged as the treatment of choice for uncomplicated cholelithiasis. Despite early concerns, many surgeons have applied this new technique to more complicated biliary tract disease states, including biliary pancreatitis. To evaluate the safety of laparoscopic cholecystectomy in this setting, we retrospectively reviewed 29 patients with clinical and laboratory evidence of biliary pancreatitis who underwent this procedure between March 1990 and December 1992. The severity of pancreatitis was determined by Ranson's criteria. Two patients had a Ranson's score of 6, one of 5, one of 4, five scored 3, nine scored 2, nine also scored 1, and two patients scored 0. The mean serum amylase level on admission was 1,610 (range 148 to 7680). All patients underwent laparoscopic cholecystectomy during the same hospital admission for biliary pancreatitis, with the mean time of operation being 5.5 days from admission. Operative time averaged 123 minutes (range 60-220 minutes). Intraoperative cholangiography was obtained in 76 per cent of patients. Three patients had choledocholithiasis on intraoperative cholangiography and were treated with choledochoscopy, laparoscopic common bile duct exploration, and saline flushing of the duct. The mean length of hospital stay was 11 days (range 5-32 days). There were seven postoperative complications requiring prolonged hospitalization with all but one treated non-operatively. One patient with a preoperative Ranson score of 6 developed necrotizing pancreatitis and subsequently required operative pancreatic debridement and drainage. There were no deaths in this series and no postoperative wound infections. The average recovery period for return to work was 2 weeks. These statistics compare favorably with literature reports for open cholecystectomy in biliary pancreatitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Advances in laparoscopic technique have provided the opportunity to perform preperitoneal herniorrhaphy and potentially avoid the morbidity associated with open techniques. From January 1991 to May 1992, two primary surgeons repaired 63 inguinal hernias (42 indirect, 20 direct, 1 femoral) on 48 patients using a standardized laparoscopic technique. The hernia defect was visualized laparoscopically, and the peritoneum anterior to the defect was incised. The hernia sac was dissected from the inguinal canal. The hernia defect was then loosely packed with rolled 1 x 6-inch polypropylene mesh (average number of rolls used was 3.4). A sheet of polypropylene mesh (average 5 x 8 cm) was then placed over the mesh rolls and the hernia defect and anchored with an endostapler. The peritoneum was closed over the mesh sheet with standard laparoscopic clips. There were 44 males and 4 females in the study group. The mean age was 55 years (range, 17-89 years). The mean follow-up was 5.8 months (range, 1-12 months). Thirty-three patients underwent unilateral hernia repair, and 15 patients underwent bilateral hernia repair. Clinically unsuspected contralateral hernias were identified at the time of laparoscopy in seven patients. The mean duration of surgery was 118 minutes (range, 80-165 minutes) for bilateral hernia repair, and 70 minutes (range, 45-100 minutes) for unilateral hernia repair. All patients with laparoscopic hernia repairs were treated on a same-day or less-than-24-hour in-hospital stay. Complications were designated as minor, moderate, or severe. There were 14 minor complications, which included subcutaneous hematomas at the trocar site, scrotal ecchymosis, groin swelling emphysema, and testicular asymmetry.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic cholecystectomy has become the procedure of choice in most hospitals for the resolution of surgically treatable gallbladder disease. Few reports address the results of laparoscopic cholecystectomy in comparison to open cholecystectomy during the same time interval within the same institution. One hundred ninety-six laparoscopic cholecystectomies were performed from April 1990 through February 1991. Initial patient selection was restricted to elective procedures for chronic cholecystitis with expanded indications as experience was gained. Of the 196 cases, 11 required conversion to open cholecystectomy, leaving 185 laparoscopic cholecystectomies for comparison. During the same period, 82 open cholecystectomies were performed. Thirty-nine of these were complicated cases and would not have been considered for laparoscopic cholecystectomy early in the study, leaving 43 routine open cholecystectomies for comparative purposes. In the laparoscopic group, 1.1 per cent of the patients had major operative complications as opposed to the open group, which had none. There were no common bile duct injuries in either group. To provide a true cost-benefit analysis, a group of patients was identified that would qualify for elective, same-day admission for either an open or laparoscopic procedure. Laparoscopic cholecystectomy (LC) was performed on 70 patients, and open cholecystectomy (OC) was performed on 26 patients. A comparison of data from these groups showed no significant difference in age or sex. Hospitalization costs averaged $5,390 for the LC group versus $5,392 for the OC group. Postoperative hospital stay averaged 1.3 days for the LC group versus 3.7 days for the OC group (P < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

A simplified method of laparoscopic inguinal herniorrhaphy using prosthetic materials was evaluated in a swine hernia model. The goals of this study were to determine 1) effectiveness of repair in a rapidly growing animal, 2) effectiveness and extent of adhesion formation of different prosthetic materials, 3) the effect of repair on testicular growth, and 4) histologic effects on the hernia site and surrounding structures. In a prospective randomized study, 30 juvenile male swine (average, 23 kg) with 35 congenital indirect inguinal hernias underwent laparoscopic herniorrhaphy using one of three prosthetic materials: Group 1 (polytetrafluoroethylene/Gore-Tex), N = 10; Group 2 (polypropylene mesh/Marlex), N = 10; Group 3 (polypropylene mesh/Prolene), N = 10. A standardized laparoscopic herniorrhaphy technique consisting of stapling prosthetic material over the hernia defect without peritoneal dissection was employed. During the 3-month postoperative period, animals were sequentially examined for normal growth and development, normal testicular development, and signs of hernia recurrence. Clinically apparent complications related to herniorrhaphy occurred in five animals (17%) during the observation period (one with repair failure, one with testicular torsion, two with repair failure and bowel obstruction, and one with intestinal obstruction secondary to adhesions). All three animals with bowel obstruction died. At 90 days after surgery all remaining animals (N = 27) were euthanized (Group 1 = 9, Group 2 = 8, Group 3 = 10). Average weight was 84 kg. Necropsy findings included no additional hernia recurrences, and one mesh erosion into the urinary bladder.(ABSTRACT TRUNCATED AT 250 WORDS)

The records of 136 patients with periampullary and pancreatic carcinoma were reviewed and the information compared with other reported series. The clinical presentation with jaundice without other manifestations is associated with the greatest number of potentially curable tumors. The majority of patients were treated by palliative bypass or had exploration and biopsy only. A tissue diagnosis is not imperative before radical excision, providing a systematic preoperative and operative evaluation indicates tumor. Ligation of the pancreatic duct with external drainage results in low morbidity and mortality and good functional results. Radical pancreaticoduodenectomy done in 21 per cent of our patients offers the best palliation and the only hope for cure.