Avoiding Cribari gridlock 2: The standardized triage assessment tool outperforms the Cribari matrix method in 38 adult and pediatric trauma centers.

OBJECTIVES: The Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample. METHODS: Thirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005. RESULTS: Overtriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar. CONCLUSIONS: This multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.

Rethinking the definition of major trauma: The need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

BACKGROUND: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS. METHODS: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS). RESULTS: The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46-10.53]; ISS = 5.94 [5.36-6.60], RTS = 4.79 [4.29-5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08-3.22], ISS = 2.87 [2.80-2.94], RTS = 2.37 [2.30-2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52-2.66], ISS = 2.51 [2.44-2.59], RTS = 2.37 [2.28-2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84. CONCLUSION: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments. LEVEL OF EVIDENCE: Prognostic, level IV.

Socioeconomic factors and parity of access to robotic surgery in a county health system.

Equal access to novel surgical technologies remains a policy concern as hospitals adopt robotic surgery with increasing prevalence. This study sought to determine whether socioeconomic factors influence access to robotic surgery. All laparoscopic and robotic fundoplications and paraesophageal hernia repairs performed by a surgical group over 6 years at a county and two neighboring private hospitals were identified. Robotic use by hospital setting, age, gender, reported ethnicity, estimated income, insurance payer, and diagnosis were examined. Of 418 patients identified, 180 (43%) presented to the county hospital, where subjects were younger (51.1 versus 56.2 years, p < 0.001) with lower estimated income ($50,289 versus $62,959, p < 0.001). In the county setting, there was no difference in reported ethnicity (p = 0.169), estimated income (p = 0.081), or insurance payer (p = 0.535) between groups treated laparoscopically versus robotically. There was no difference in the treatment groups by estimated income in the private hospital setting (p = 0.308). Overall higher estimated income and insurance payer were associated with a higher chance of undergoing robotic procedures (p < 0.001). Presence of a paraesophageal hernia was associated with increased chance of undergoing robotic therapy in all comparisons (p < 0.001). No disparity in access to robotic surgery offered in the county hospital was observed based on age, gender, reported ethnicity, estimated income, or insurance payer. Patients with higher income and private insurers were more likely to present to the private hospital setting where robotics is utilized more often. The presence of a paraesophageal hernia was a significant factor in determining robotic therapy in both settings.

Traumatic Abdominal Solid Organ Injury Patients Might Benefit From Thromboelastography-Guided Blood Component Therapy.

BACKGROUND: Thromboelastography (TEG) has been utilized for the guidance of blood component therapy (BCT). We aimed to investigate the association between emergent TEG-guided BCT and clinical outcomes in patients with traumatic abdominal solid organ (liver and/or spleen) injuries. METHODS: A single center retrospective study of patients who sustained traumatic liver and/or spleen injuries receiving emergent BCT was conducted. TEG was ordered in all these patients. Patient demographics, general injury information, outcomes, BCT, and TEG parameters were analyzed and compared in patients receiving TEG-guided BCT versus those without. RESULTS: A total of 166 patients were enrolled, of whom 52% (86/166) received TEG-guided BCT. A mortality of 12% was noted among patients with TEG-guided BCT when compared with 19% of mortality in patients with non-TEG-guided BCT (P > 0.05). An average of 4 units of packed red blood cell (PRBC) was received in patients with TEG-guided BCT when compared to an average of 9 units of PRBC received in non-TEG-guided BCT patients (P < 0.01). A longer hospital length of stay (LOS, 19 ± 16 days) was found among non-TEG-guided BCT patients when compared to the TEG-guided BCT group (14 ± 12 days, P < 0.05). TEG-guided BCT showed as an independent factor associated with hospital LOS after other variables were adjusted (coefficiency: 5.44, 95% confidence interval: 0.69 - 10.18). CONCLUSIONS: Traumatic abdominal solid organ injury patients receiving blood transfusions might benefit from TEG-guided BCT as indicated by less blood products needed and less hospitalization stay among the cohort.

Prophylactic Gentamicin Is Not Associated with Acute Kidney Injury in Patients with Open Fractures.

BACKGROUND: Data on antimicrobial prophylaxis for open fractures is limited, with many protocols based on expert recommendations. These protocols include aminoglycosides (AGs) for fractures with significant soft tissue injury, but these drugs are associated with acute kidney injury (AKI) in other settings; this risk has not been defined for open fracture prophylaxis. METHODS: We performed a retrospective study from May 2012 to October 2014 at our Level 1 trauma center. Patients with open fractures were evaluated for demographics, location/type of fracture, injury severity, and receipt of an AG. Outcomes included rates of AKI, infection, and mortality. RESULTS: There were 167 patients with open fractures during the study period (119 males, mean age 42 ± 17 [standard deviation] years), with 80 (48%) receiving prophylactic gentamicin (AG+ group). The AG+ and AG- patients had similar fracture sites and Injury Severity Scores (ISSs) (12.6 ± 9.9 AG+ vs. 15.9 ± 13.2 AG-) but were more likely to have sustained blunt trauma (96% AG+ vs. 77%; p < 0.001) or received intravenous contrast medium ≤48 h from admission (75% AG+ vs. 56% AG-; p = 0.01). Gentamicin was not associated with AKI (odds ratio [OR] 0.22; 95% confidence interval [CI] 0.020-2.44; p = 0.22), whereas hypotension on admission (OR 10.7; 95% CI 1.42-80.93; p = 0.02) and ISS (OR 1.1; 95% CI 1.01-1.20; p = 0.02) were both associated with AKI. Only four fracture site infections were identified, three in the AG+ group and one in the AG- group (3.8% vs. 1.1%; p = 0.27). The mortality rate was greater in the AG- group (3.8% vs. 12.6%; p = 0.04). CONCLUSIONS: Prophylactic gentamicin is not associated with AKI, whereas hypotension on admission and higher ISS were. The use of nephrotoxic agents, including aminoglycosides, should be restricted in open fracture patients presenting with hypotension or a high ISS.

Long-term preclinical evaluation of the intracorporeal use of advanced local hemostatics in a damage-control swine model of grade IV liver injury.

BACKGROUND: The purpose of this study was to evaluate the long-term efficacy and safety of kaolin- and chitosan-based hemostatic agents for hemorrhage control in a 14-day survival, damage-control swine model of Grade IV liver injury. METHODS: A total of 48 anesthetized pigs (40 kg) underwent a 35% total blood volume bleed, cooling to 34°C and a standardized liver injury. The animals were randomized to standard gauze control (SG, n = 12), QuikClot Combat Gauze (QCCG, n = 12), Celox (CX, n = 12), or Celox Gauze (CXG, n = 12) packing. At 15 minutes, shed blood was calculated, followed by damage-control closure. At 48 hours, pack removal and definitive closure was performed. At 14-day sacrifice, the liver, kidney, heart, lung, and small bowel standard intra-abdominal organs were sampled for histopathological examination. RESULTS: Uncontrolled blood loss at 2 minutes demonstrated internal consistency of the injury. Blood loss at 15 minutes was significantly lower in the CX and QCCG arms (SG, 11.1 ± 1.1 mL/kg; QCCG, 5.3 ± 1.2 mL/kg; CX, 5.7 ± 1.2 mL/kg; and CXG, 10.1 ± 1.3 mL/kg; p = 0.002). Forty-eight-hour survival was 50.0% for SG, 58.3% for QCCG, 83.3% for CX, and 41.7% for CXG (p = 0.161). Fourteen-day survival was 41.7% (5) for SG, 50.0% (6) for QCCG, 58.3% (7) for CX, and 41.7% (5) for CXG (p = 0.821). Four CX and two QCCG deaths were caused by bowel obstruction; one SG death was caused by sepsis; the remainder was caused by blood loss.Histopathology in one CX animal demonstrated eosinophilic material within a coronary vessel consistent with granule embolization. CONCLUSION: Celox and QuikClot Combat Gauze were effective hemostatic adjuncts to standard intracavitary damage-control packing. The hemostasis was durable, facilitating pack removal, and definitive closure at reoperation. There was however an increase in the development of intra-abdominal adhesions resulting in small bowel obstruction. The potential for distant embolization of granular agents warrants further investigation.

The impact of early hormonal therapy in catastrophic brain-injured patients and its effect on organ procurement.

The purpose of this study was to evaluate the impact of early hormonal therapy on organ procurement from catastrophic brain-injured patients. All catastrophic brain-injured patients admitted to a high-volume academic Level I trauma center who underwent successful organ procurement over a 3-year period (2006 to 2008) were reviewed. Patients were divided into two groups, those who received hormone therapy (HT) before brain death (BD) declaration and those who received HT after BD declaration. Thirty-two (60.4%) received HT before BD and 21 (39.6%) HT after BD. Trauma was the most common cause of brain injury in both groups (before BD 96.9 vs after BD 90.5%, P = 0.324). There were no significant differences in demographics and clinical data. Patients receiving HT before BD were more hypotensive on admission (28.2 vs 9.5%, P = 0.048); however, they required vasopressors less frequently (62.5 vs 100.0%, P = 0.001), for a shorter duration (17.2 ± 16.3 hours vs 33.1 ± 34.9 hours, P = 0.043), and at a lower dosage. Time from admission to procurement did not differ between the two groups (109.8 ± 83.1 hours vs 125.0 ± 79.9 hours, P = 0.505). Patients receiving HT before BD had significantly more organs procured (4.5 ± 1.5 vs 3.5 ± 1.3, P = 0.023). Although catastrophic brain-injured patients receiving early hormonal therapy were more hypotensive, they required less vasopressors and had higher procurement rates. The early use of hormonal therapy may decrease the need for vasopressors and increase the salvage of potentially transplantable organs.

Intracorporeal use of advanced local hemostatics in a damage control swine model of grade IV liver injury.

BACKGROUND: The purpose of this study was to evaluate the efficacy of zeolite- and chitosan-based local hemostatic agents for the control of intracorporeal bleeding in a damage control swine model of grade IV liver injury. METHODS: Anesthetized pigs (weight, 40 kg) had a controlled 35% total blood volume bleed from the right jugular vein. A laparotomy was performed and the animals were cooled to 35°C. Ringer's lactate was titrated to achieve a three to one blood withdrawal resuscitation. The liver was injured with a standardized 10 cm × 3 cm avulsion. After 2 minutes of uncontrolled hemorrhage, the animals were randomized to application of gauze control (GC, n = 11), Celox (CX, n = 11) (5AM Medical, Newport, OR), or QuikClot ACS (QC, n = 11) (7-Medica, Wallington, CT) and packed in a standardized manner. At 10 minutes, the packs were removed to calculate amount of shed blood. The animals then underwent damage control closure with packing in place. Forty-eight hours after initial damage control packing, the animals were returned to the operating room for pack removal and killing. The need for repacking of the liver was assessed and tissue samples were collected from the liver edge and adjacent small bowel for histopathology. RESULTS: There was no difference in the amount of uncontrolled bleeding at 2 minutes (GC: 4.0 mL/kg ± 0.4 mL/kg, CX: 3.5 mL/kg ± 0.5 mL/kg, QC: 4.0 mL/kg ± 0.6 mL/kg; one-way analysis of variance: p = 0.715). Compared with GCs, the blood loss at 10 minutes was significantly lower in the CX and QC arms (GC: 8.3 mL/kg ± 0.9 mL/kg, CX: 3.7 mL/kg ± 0.7 mL/kg, QC: 4.6 mL/kg ± 0.8 mL/kg; one-way analysis of variance: p = 0.001). A total of 27.3% of control animals died compared with 18.2% of CX and 0.0% of QC. All GC and QC animals required repacking, compared with one (9.1%) of those in the CX arm. There was no difference between groups in the extent of necrosis. CONCLUSION: Celox and QuikClot ACS(+) are effective adjuncts to standard intracavitary damage control packing for the control of bleeding. Celox provided durable control allowing packing removal at the time of take-back laparotomy. Further evaluation of their long-term effects is warranted.

The relationship between post-traumatic ventilator-associated pneumonia outcomes and American College of Surgeons trauma centre designation.

INTRODUCTION: The relationship between outcomes following severe trauma and American College of Surgeons (ACS) trauma centre designation has been studied. Little is known, however, about the association between ACS level and outcomes associated with ventilator-associated pneumonia (VAP). METHODS: The National Trauma Databank (NTDB, Version 5.0) was queried to identify adult (age 18)trauma patients who (1) developed VAP and (2) were admitted to either an ACS level I or level II centre.Transfer and burn patients were excluded. Univariate analysis defined differences between patient cohorts. Logistic regression analysis was utilised to identify independent risk factors for mortality. RESULTS: A total of 3465 patients were identified where 65.6% were admitted to a level I facility and 34.4%to a level II centre. Patients admitted to a level I centre were more likely to have an age > 55 (71.5% vs.66.8%, p = 0.004) and to be hypotensive (SBP < 90) on admission (16.2% vs. 13.6%, p = 0.042). They were also more likely to have a longer duration of mechanical ventilation (18.5 days vs. 16.5 days, p = 0.001),longer hospital LOS (34.2 days vs. 29.6 days, p < 0.001) and a higher rate of early (±7 days) tracheostomy(33.1% vs. 29.1%, p = 0.017). Level I admission was, however, associated with lower mortality rates (10.8%vs. 14.7%, p = 0.001) and a higher likelihood of achieving discharge to home (20.2% vs. 16.1%, p < 0.001).Logistic regression analysis identified admission to a level II facility as an independent risk factor for mortality (OR 1.34, 95% CI 1.08­1.66; p = 0.008) in patients developing post-traumatic VAP. CONCLUSION: For adults who develop VAP after trauma, admission to a level I facility is associated with improved survival. Further prospective study is needed.

A new survivable damage control model including hypothermia, hemodilution, and liver injury.

BACKGROUND: The purpose of this article is to describe a new model of traumatic intra-cavitary hemorrhage in a hypothermic, hemodiluted liver injury model that incorporates damage control principles and allows for survival. MATERIALS AND METHODS: Twenty swine underwent a standardized 35% blood volume hemorrhage followed by resuscitation. Ten animals sustained nonsurgical and 10 a surgical high-grade liver injury. In the surgical liver injury, damage control gauze packing was performed. No operative treatment was provided for the nonsurgical liver injury, which was designed to test the efficacy of systemic hemostatic agents. After a 15 min treatment phase, the abdominal cavity was closed, with the packing in place for the surgical injury, and all animals were resuscitated. Necropsy was performed at 48 h post-injury. RESULTS: At the time of liver injury, the animals were hemodiluted and hypothermic. Both injuries caused a 20% drop in the mean arterial pressure from baseline (P<0.001). Comparing baseline thromboelastography results with the results after hemodilution, hypothermia, and liver injury, a hypercoagulopathic state was observed. Mortality was 30% for both types of liver injury. The mean volume of intra-abdominal blood present at autopsy was similar for both types of liver injuries (202 ± 161 mL and 214 ± 203 mL, respectively). CONCLUSION: A new model of traumatic intra-cavitary hemorrhage in a hypothermic, hemodiluted liver injury model with damage control that allows for survival has been described. The mortality rate of 30% allows for the comparison of therapeutic interventions that may lead to improved survival.

The impact of Acinetobacter baumannii infections on outcome in trauma patients: a matched cohort study.

OBJECTIVE: To determine the impact of Acinetobacter baumannii infection on the outcome of trauma patients. DESIGN AND SETTING: A retrospective 1:2-matched cohort study. Level I trauma intensive care unit patients with confirmed Acinetobacter baumannii infection were defined as cases. PATIENTS: Thirty-one Acinetobacter baumannii patients were matched to 62 controls with evidence of infection caused by other microorganisms. MEASUREMENTS AND MAIN RESULTS: There were 12 matching criteria, including focus of infection, demographics, severity, and characteristics of injury. In-hospital mortality rate, intensive care unit length of stay, and complications of Acinetobacter baumannii including multidrug-resistant strains in patients were compared to those of their controls; 81% had hospital-acquired pneumonia, 13% had bloodstream infections, and 6% had urinary tract infections in both groups. Acinetobacter baumannii cultures were multidrug resistant in 42% (13/31) of cases. The initial empirical antibiotic therapy was adequate in 71% (22/31). Although the in-hospital mortality was higher in the Acinetobacter baumannii group (16% vs. 13%; odds ratio, 1.23; 95% confidence interval, 0.38-4.36; p = .67), the difference did not reach statistical significance. Using the test of equivalence or clinical indifference, the impact of an Acinetobacter baumannii infection on mortality is inconclusive. This applies also to multidrug-resistant strains. Overall intensive care unit stay was prolonged for Acinetobacter baumannii when compared to controls (median, [range], 28 [7-181] days vs. 17 [2-130] days, respectively; p = .05). ARDS and acute liver failure were more frequent in the Acinetobacter baumannii group compared to the control group (35% vs. 15%; odds ratio, 3.24; 95% confidence interval, 1.17-5.48; p = .02 and 26% vs. 10%; odds ratio, 3.25; 95% confidence interval, 3.25-10.40; p = .04). CONCLUSIONS: In this single-center experience, Acinetobacter baumannii infection, including multidrug-resistant strains, has inconclusive impact on mortality in a cohort of trauma patients. Larger studies are needed to support a definite conclusion. Acinetobacter baumannii infection was, however, associated with a longer intensive care unit stay and a higher rate of organ failure.

American College of Surgeons trauma centre designation and mechanical ventilation outcomes.

OBJECTIVE: The association between hospital volume and outcomes following mechanical ventilation has been previously examined in diverse patient populations. The American College of Surgeons (ACS) Committee on Trauma has outlined criteria for trauma centre level designations with specific requirements for both specialty capabilities and hospital volume. Our objective is to determine the relationship between ACS centre designation and outcomes for trauma patients undergoing mechanical ventilation. METHODS: We conducted a retrospective cohort study using the National Trauma Databank (NTDB), identifying 13,933 adult (age>or=18) trauma patients receiving mechanical ventilation for greater than 48 h from 2000 to 2004 who were admitted to either an ACS Level I or Level II trauma centre. The primary endpoints examined were mortality, pneumonia and Acute Respiratory Distress Syndrome (ARDS). Univariate analysis defined differences between those patients admitted to ACS Level I and Level II facilities. Logistic regression analysis was used to identify if ACS level designation was an independent risk factor for the goal outcomes. RESULTS: Patients admitted to a Level I facility and mechanically ventilated for greater than 48 h were more commonly greater than age 55 (71.3% vs. 67.9%, p<0.01), hypotensive (SBP<90) (16.1% vs. 12.8%, p<0.01), and likely to have sustained injury due to penetrating mechanism (11.1% vs. 5.1%, p<0.01). On univariate analysis, mortality and the incidence of pneumonia did not differ between the two groups. Level I admission was, however, less commonly associated with the development of ARDS (5.8% vs. 7.7%, p<0.01) and patients admitted to Level I facilities were significantly more likely to be discharged to home than Level II counterparts (29.7% vs. 22.9%, p<0.01). Logistic regression revealed that, while ACS Level designation was not a predictive factor for mortality or the development of pneumonia, admission to an ACS Level II facility was an independent predictor for the development of ARDS [p<0.01, odds ratio, 95% CI: 1.35 (1.18-1.59)]. CONCLUSION: For trauma patients requiring mechanical ventilation for >48 h, ACS trauma centre designation had no effect on overall mortality or the incidence of pneumonia. Compared to Level I counterparts, however, patients admitted to an ACS Level II facility were significantly more likely to develop ARDS following trauma. This finding needs further investigation in a large, prospective analysis.

Pyloric exclusion in the treatment of severe duodenal injuries: results from the National Trauma Data Bank.

Pyloric exclusion (PEX) has traditionally been used in the management of complicated duodenal injuries to temporarily protect the duodenal repair and prevent septic abdominal complications. We used the American College of Surgeons National Trauma Data Bank (v 5.0) to evaluate adult patients with severe duodenal injuries [American Association for the Surgery of Trauma (AAST) Grade > or = 3] undergoing primary repair only or repair with PEX within 24 hours of admission. Propensity scoring was used to adjust for relevant confounding factors during outcomes comparison. Among 147 patients with severe duodenal injuries, 28 (19.0%) underwent PEX [15.9% (11/69) Grade III vs 34.0% (17/50) Grade IV-V]. Despite similar demographics, PEX was associated with a longer mean hospital stay (32.2 vs 22.2 days, P = 0.003) and was not associated with a mortality benefit. There was a trend toward increased development of septic abdominal complications (intra-abdominal abscess, wound infection, or dehiscence) with PEX that was not statistically significant. After multivariable analysis using propensity score, no statistically significant differences in mortality or occurrence of septic abdominal complications was noted between those patients undergoing primary repair only or PEX. The use of PEX in patients with severe duodenal injuries may contribute to longer hospital stay and confers no survival or outcome benefit.

Surgical treatment of advanced-stage carcinoid tumors: lessons learned.

OBJECTIVE: To evaluate clinical outcomes in a large group of advanced-stage carcinoid patients (stage IV) following multimodal surgical therapy. SUMMARY BACKGROUND DATA: Patients with advanced-stage carcinoid have traditionally experienced poor 5-year survival (18%-30%). Few recent series have evaluated a large number of patients treated with aggressive surgical rescue therapy. METHODS: This single-center retrospective review analyzes the records of 82 consecutive carcinoid patients treated by the same 2 surgeons, from August 1998 through August 2004 with a 3- to 72-month follow-up. RESULTS: Surprisingly, one third of 26 (32%) patients were found to have intestinal obstructions; 10 being moribund at presentation. Mesenteric encasement with intestinal ischemia was successfully relieved in 10 of 12 cases. Five of eighty-two "terminal" patients were rendered free of macroscopic disease. Karnofsky performance scores improved from 65 to 85 (P < 0.0001). Two- and four-year survival for patients with no or unilateral liver metastases (n = 23) was 89%, while 2- and 4-year survival for patients with bilateral liver disease (n = 59) was 68% and 52% (P = 0.072), respectively. CONCLUSION: We think that all patients with advanced-stage carcinoid should be evaluated for possible multimodal surgical therapy. Primary tumors should be resected, even in the presence of distant metastases to prevent future intestinal obstruction. The "wait and see" method of management of this slow-growing cancer no longer has merit. We offer an algorithm for the surgical evaluation and management of these patients.