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The purpose of this study was to determine if the quantity and age of blood is an independent risk factor for in-hospital mortality, need for intensive care unit (ICU) care, and an increased length of stay in the ICU. This was a retrospective cohort study performed at a level I trauma center between 2001 and 2003. Consecutive trauma patients who received at least 1 unit of packed red blood cells (PRBCs) were included. The number of units of PRBCs transfused and the ages of each unit of PRBCs were recorded. Other variables including the patient's age, sex, Trauma-Related Injury Severity Score (TRISS), and whether the blood was leukopoor were collected. End points included in-hospital mortality, need for ICU care, and the length of stay in the ICU (in days). Multivariable logistic and Poisson regression analyses were performed to model the independent effect of the dose of aged blood (defined as the product of the average age of all units received and the total number of units received) with respect to each end point while controlling for age, TRISS, the total number of units administered, and the proportion of blood that was leukopoor. During the study period, 275 patients were studied. Patients who received older blood had a significantly longer ICU stay (RR 1.15, 95% CI: 1.11-1.20), possibly reflecting a higher level of organ dysfunction. Patients who received older blood, however, did not have a significantly higher in-hospital mortality rate (OR 1.21, 95% CI: 0.87-1.69) or a significantly higher need for ICU care (OR 1.20, 95% CI: 0.87-1.64). The quantity of aged blood is an independent risk factor for length of ICU care. This may be a proxy indicator for multiple organ failure. Further research is required to define which patients may benefit from newer blood.

Sentinel lymph node (SLN) biopsy is an accurate technique to determine the metastatic status of lymph nodes. Radionuclide guidance makes the procedure easier and improves the success rate. Coordinating the operating room and nuclear medicine schedules causes delays when same-day radionuclide injection is used. We hypothesized that injection of 99m-Tc sulfur colloid immediately preoperatively is effective in SLN detection. We analyzed a prospective database of 70 patients treated at Harbor-UCLA Medical Center. The first 39 patients underwent completion axillary dissection (Group A) and subdermal injection of sulfur colloid immediately before surgery. A second group of 31 patients (Group B) had intraparenchymal injection immediately before surgery. We used isosulfan blue in all cases. SLNs were identified in 97 per cent of cases. SLNs were radioactive in 94 per cent and blue in 90 per cent. In Group A the accuracy and the positive and negative predictive values of SLN biopsy were 100 per cent. SLN counts per second ranged from 22 to 1700. The mean count per second was 290 +/- 281 (mean +/- standard deviation). Subdermal and intraparenchymal injections were equally successful (93% vs 92%). In conclusion injection of radiocolloid and isosulfan blue immediately preoperatively is highly successful and accurate in the detection of SLNs in breast cancer. It avoids operating room schedule delays.

Sentinel lymph node (SLN) biopsy is increasingly being used as an accurate and less morbid surrogate for axillary dissection. However, a standardized technique in the biopsy of SLNs is not used. Some authors propose subdermal injection to be as accurate as peritumoral intraparenchymal injection (IPI). Our objective is to determine whether the SLNs identified by subdermal injection truly represent SLNs and match those found with IPI. Specific end points of the study were 1) successful localization of the SLN by the IPI of isosulfan blue or the radiocolloid intradermal injection, 2) successful uptake of radiocolloid and isosulfan blue on individual SLN, and 3) determination of the frequency with which the radiocolloid injection detected the "gold standard" blue SLN. SLNs were found in 71 of 73 cases (success rate = 97%). Blue SLNs were identified in 64 patients (88%). SLNs in 61 patients (84%) were radioactive. A total of 112 SLNs were identified in 71 patients (1.6 nodes/patient). Seventy-six of 87 SLNs found with IPI were also radioactive (concordance of 87%). All SLNs harboring metastatic cancer (16 patients) were found by both techniques, being both blue and radioactive. Our results support the concept of shared lymphatic pathways in the breast with a high degree of communication between the subdermal lymphatics and the intraparenchymal lymphatics. The success in identification of the SLN is made simpler and improved by the addition of subdermal radiocolloid injection.

The ability to recognize multicentric breast cancer preoperatively would assist in identifying appropriate candidates for breast conservation surgery. Tc-99m scintimammography (SMM) is an adjunct to conventional mammography in identifying selected patients with breast cancer. The purpose of this study is to report the utility of SMM in identifying patients with multicentric breast cancer. Breast cancer patients treated by mastectomy who underwent a preoperative SMM between 1992 and 1999 were identified using the institution's Tumor Registry. The pathology report of each patient was reviewed for multicentric disease defined as an additional focus of cancer within a different quadrant of the breast or greater than 2.5 cm from the dominant tumor mass. Each patient's preoperative SMM was reviewed and compared with the pathologic findings to obtain correlative data. Fifty-eight women treated by mastectomy had preoperative SMM (age range 35-78 years; median 52 years). Pathology revealed infiltrating ductal carcinoma in 49 patients (84.5%), infiltrating lobular carcinoma in five patients (8.6%), ductal carcinoma in situ in three patients (5.1%), and colloid carcinoma in one patient (1.7%). Multicentric disease was present in the specimens of eight patients for a prevalence of 10.3 per cent. SMM was positive for uptake in 36 of 58 patients (sensitivity 62.1%). The sensitivity, specificity, positive predictive value, and negative predictive value of SMM in the detection of multicentric disease were 62.5, 96, 71, and 94 per cent, respectively. Although the overall sensitivity of SMM in the detection of breast cancer is superior to that of conventional mammography and physical examination in identifying multicentric breast cancer it is not an accurate modality for detecting multicentric disease in this study group. However, it may have limited applications in specific cases.

Historically, axillary lymph node dissection (ALND) was a critical aspect of the operative management of breast cancer. Recently, the role of ALND has been questioned, with postoperative morbidity possibly overshadowing patient benefit. Our objective was to quantitatively assess the long-term morbidity of ALND in patients with breast cancer. We conducted a cross-sectional study of patients being followed by the Breast Surgery Clinic at a university-affiliated urban hospital. Ninety-five patients with unilateral breast cancer who had undergone ALND were evaluated at routine follow-up visits in the latter half of 1998. A questionnaire was used to quantify the degree of subjective findings, including arm swelling, chest wall pain, decreased mobility, and weakness. Upper extremity strength, active range of motion, and circumference were measured. Overall, 70 per cent of patients had at least one complaint, with 18 per cent having moderate to severe symptoms. Twenty-one per cent had notable decrements in strength or range of motion, 9.3 per cent of patients required chronic compression garments for lymphedema, and 6.4 per cent changed their vocational status because of surgical morbidity. We conclude that adverse effects from ALND occur commonly. Objective findings are less common, perhaps causing clinicians to underappreciate postoperative morbidity. A significant subset of patients had enduring disability.

In a retrospective review covering 16 years divided into two time periods, 133 patients with amebic liver abscess were evaluated. Most of the patients were young, Hispanic men, and one-third had coexistent disease. A reliable diagnosis can be established in 24 hours using ultrasound or computed tomography scans. Over the entire time period, antiparasitic therapy was evolved to occupy a primary role and surgery was reserved for management of abscess complications.

Tumor necrosis factor (TNF) is a postulated proximal septic mediator. The authors compared the time course and extent of the cardiopulmonary effects of recombinant human TNF (rTNF) in swine vs those of Escherichia coli endotoxin (ETX). Intravenous boluses of either rTNF (n = 4), ETX (n = 2), or saline (n = 4) were given to swine. Mean pulmonary artery pressure and extravascular lung water (EVLW) were increased at 60 minutes for rTNF and ETX to 31 +/- 2 mmHg and 33 +/- 3 mmHg and 6.3 +/- 0.9 ml/kg and 7.1 +/- 1.6 ml/kg, while saline animals were unchanged. The authors conclude that rTNF mimics ETX both in time course and magnitude of effects. Right-sided cardiopulmonary effects predominate in both with minimal left-sided effects at these dosages. The time course of early increased EVLW suggests an initial hydrostatic influence on pulmonary edema formation in this septic model.

In 1983, Los Angeles County designated 23 level I or II trauma centers. During the subsequent 7 years, ten centers closed because of adverse financial impact. To analyze the causes of this trend, hospital admissions for gunshot and stabbing injuries were reviewed for two separate 1-year periods at a level I urban trauma center. Of 1,160 patients arriving with injuries meeting county triage criteria from January 1, 1986 through December 31, 1986, 323 (27%) sustained penetrating assault, of which 96 were with firearms (30%). From January 1, 1988 through December 31, 1988, 1,213 met triage criteria; 301 (25%) were intentional, of which 179 (59%) were due to firearms. Epidemiologic and clinical data from the two periods is similar with 90 per cent of the patients being men ages 25 to 30 and of minority ethnic background. Seventy-five per cent of the patients required a truncal operative procedure and needed about 5.5 days of hospitalization. Overall, mortality averaged 4.7 per cent and morbidity 14.5 per cent. Complete financial data was available on 561 of the 624 intentionally injured patients for which costs totaled $2,481,346 (mean = $5,260 for gunshots; mean = $3,640 for stab wounds). The total collections were $545,896 (22% of total charges). Only 5 per cent of the charges were reimbursed from insurance; MediCal reimbursed 13 per cent and only 1 per cent was from Medicare. Eighty-one per cent of the patients had no financial resources, resulting in a hospital deficit of $1,861,009 (75% of the total charges).(ABSTRACT TRUNCATED AT 250 WORDS)

High risk splenectomy is often encountered in cases of hypersplenism with massive splenomegaly (10 times usual weight of 150-200 g) resulting from myelophthisic processes. Intra-operative ligation of the splenic artery through the lesser sac is a technically useful method of gaining vascular control prior to mobilizing the challenging spleen. However, a massive or inaccessible spleen imposes mechanical limitations during surgery and may be complicated by torrential intra-operative hemorrhage in the setting of severe thrombocytopenia refractile to platelet transfusions. The authors describe pre-operative intravascular proximal splenic artery control in four adult patients (3 men, 1 woman) with extreme splenomegaly (2,250-10,000 g). The massive splenomegaly in this group resulted from chronic myelogenous leukemia (n = 2), isolated splenic lymphoma (n = 1), and agnogenic myeloid metaplasia (n = 1). Chief symptom manifestations included left upper quadrant abdominal pain, early satiety, post-prandial emesis, dyspnea, petechiae, and associated easy bruising. Prior to surgery, all the patients were taken to the radiology suite where either detachable silastic balloons or stainless steel coils were placed selectively into the splenic artery under fluoroscopic guidance requiring approximately 35 minutes. Splenic artery occlusion aided normalization of thrombocytopenia (average increases 19,000/microliter to 215,000/microliter) with prolongation in survival of platelets. Successful splenectomy was subsequently performed with no additional transfusion requirements and was made technically easier by reducing splenic bulk. There were no adverse consequences of intravascular occlusion and no peri-operative morbidity or mortality. Preoperative intravascular selective splenic artery occlusion, used as an important potential adjunct to anticipated high risk splenectomy, is recommended.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonautologous, highly concentrated human fibrinogen and clotting factors were used in the form of fibrin glue to treat three patients with varied surgical problems that were resistant to conventional treatment. Fibrin glue was used to occlude longstanding enterocutaneous fistulae, control liver hemorrhage in an alcoholic patient with coagulopathy, and perform a splenorrhaphy, following a gunshot wound to the spleen. Fibrin glue is effective in establishing hemostasis and sealing tissues; its use is a helpful adjunct in the care of surgical patients.

In an effort to clarify the preoperative indications and factors predisposing to an increased operative morbidity for "definitive" ulcer procedures, the medical records of 114 patients with perforated duodenal ulcers were reviewed. One hundred nine patients underwent operation, with 55 patients treated with ulcer closure (Group 1) and 54 underwent a "definitive" operation (Group 2). Thirty-two complications developed in 27 patients (25%), with major infectious complications occurring in 9 per cent and 7.5 percent in the simple ulcer closure and definitive surgery groups, respectively. This study demonstrates that preoperative shock, operation delayed greater than 48 hours, and patient age greater than 60 years were significant factors increasing morbidity. The importance of peritoneal soilage and positive cultures are unreliable in predicting subsequent clinical infection and do not contraindicate definitive surgical management.