Rejuvenating the Face: An Analysis of 100 Absorbable Suture Suspension Patients.

BACKGROUND: Absorbable suture suspension (Silhouette InstaLift, Sinclair Pharma, Irvine, CA) is a novel, minimally invasive system that utilizes a specially manufactured synthetic suture to help address the issues of facial aging, while minimizing the risks associated with historic thread lifting modalities. OBJECTIVES: The purpose of the study was to assess the safety, efficacy, and patient satisfaction of the absorbable suture suspension system in regards to facial rejuvenation and midface volume enhancement. METHODS: The first 100 treated patients who underwent absorbable suture suspension, by the senior author, were critically evaluated. Subjects completed anonymous surveys evaluating their experience with the new modality. RESULTS: Survey results indicate that absorbable suture suspension is a tolerable (96%) and manageable (89%) treatment that improves age related changes (83%), which was found to be in concordance with our critical review. CONCLUSIONS: Absorbable suture suspension generates high patient satisfaction by nonsurgically lifting mid and lower face and neck skin and has the potential to influence numerous facets of aesthetic medicine. The study provides a greater understanding concerning patient selection, suture trajectory, and possible adjuvant therapies.

What Neurotoxins Have Taught Us About the Brow: The Reintroduction and Review of the Transpalpebral Browpexy.

INTRODUCTION: The use of neuromodulators has grown substantially in our society, particularly in the temporary treatment of brow ptosis. This study revisits the use of the transpalpebral browpexy for upper face and brow rejuvenation in the context of what has been learned from neuromodulators. METHODS: A retrospective review of 97 subjects was conducted who had transpalpebral browpexy performed for lateral brow ptosis. Qualitative degree of brow elevation after the procedure was determined by examining before and after photographs for each patient. RESULTS: Out of 97 patients, 95 (98%) experienced aesthetically optimal brow elevation for their respective gender. Two patients required surgical revision, both of which experienced extenuating circumstances. Two patients experienced edema and one patient experienced periodic eruptions of chalazia along the upper eyelid. CONCLUSION: Transpalpebral browpexy is a reliable, minimally invasive surgical procedure that effectively emulates the results of neuromodulator injections for a much longer period of time. While it cannot replace traditional brow-lifting techniques, transpalpebral browpexy does have solid indications with proven long-lasting results, which can be effective in a significant portion of patients with brow ptosis. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Transorbital endotracheal intubation: a nonstandard approach to a difficult airway.

We present the case report of a 49-year-old gentleman with a history of adenoid cystic carcinoma of the left nare status post curative bifrontal craniotomy, left lateral rhinotomy and medial maxillectomy, adjuvant radiotherapy, and orbital exenteration for optic neuropathy, complicated by medial wall dehiscence. His course was also complicated by severe radiation trismus, for which he was scheduled to undergo bilateral mandibular coronoidectomies. Given his limited mouth opening, the surgeon requested a nasal endotracheal tube. Because of concerns of traumatizing his nare, we utilized a flexible fiberoptic bronchoscope to perform asleep transorbital intubation. Airway management in patients with severe trismus may require ingenuity.

A Rare Case of Malignant Transformation of Oral Lichen Planus of the Mandible.

Oral lichen planus (OLP) is an immune-mediated mucocutaneous disease associated with an increased risk in oral squamous cell carcinoma (OSCC). Nearly all cases of malignant transformation have been reported in patients >40 years old. We report the case of a 37-year-old woman with a 5-year history of erosive OLP who presented with malignant transformation to OSCC. Delineating the margins of the disease was impossible at presentation given her OLP, and she was initially treated with concurrent chemoradiation therapy. She then developed a recurrence of the mandibular alveolar ridge. The patient was successfully treated with a composite resection including a segmental mandibulectomy, buccal mucosa resection, partial glossectomy, and ipsilateral neck dissection. This was reconstructed with a free fibula osteo-septo-cutaneous flap. Mandibular OSCC is a rare complication of OLP with few reports on effective reconstructive interventions. The case represents the youngest reported patient with mandibular OSCC arising in the context of OLP and highlights the utility of the free vascularized fibula graft in the treatment of these patients.

Vasopressin for cerebral perfusion pressure management in patients with severe traumatic brain injury: preliminary results of a randomized controlled trial.

BACKGROUND: After traumatic brain injury (TBI), catecholamines (CAs) may be needed to maintain adequate cerebral perfusion pressure (CPP), but there are no recommended alternative vasopressor therapies. This is an interim report of the first study to test the hypothesis that arginine vasopressin (AVP) is a safe and effective alternative to CAs for the management of CPP in patients with severe TBI. METHODS: Since 2008, all TBI patients requiring intracranial pressure monitoring at this Level 1 trauma center have been eligible for a randomized trial to receive either CA or AVP if vasopressors were required to maintain CPP greater than 60 mm Hg. RESULTS: To date, 96 patients have been consented and randomized. Demographics, vital signs, and laboratory values were similar. As treated, 60 required no vasopressors and were the least severely injured group with the best outcomes. Twenty-three patients received CA (70% levophed, 22% dopamine, 9% phenylephrine) and 12 patients received AVP. The two vasopressor groups had similar demographics, but Injury Severity Score (ISS) and fluid requirements on intensive care unit Day 1 were worse in the AVP versus the CA groups (all p < 0.05) before treatment. These differences indicate more severe injury with accompanying hemodynamic instability. Nevertheless, adverse events were not increased with AVP versus CA. Trends favored AVP versus CA, but no apparent differences were statistically significant at this interim point. There was no difference in mortality rates between CA and AVP. CONCLUSION: These preliminary results suggest that AVP is a safe and effective alternative to CA for the management of CPP after TBI and support the continued investigation and use of AVP when vasopressors are required for CPP management in TBI patients. LEVEL OF EVIDENCE: Therapeutic study, level II.

PT symmetry in classical and quantum statistical mechanics.

PT-symmetric Hamiltonians and transfer matrices arise naturally in statistical mechanics. These classical and quantum models often require the use of complex or negative weights and thus fall outside the conventional equilibrium statistical mechanics of Hermitian systems. PT-symmetric models form a natural class where the partition function is necessarily real, but not necessarily positive. The correlation functions of these models display a much richer set of behaviours than Hermitian systems, displaying sinusoidally modulated exponential decay, as in a dense fluid, or even sinusoidal modulation without decay. Classical spin models with PT-symmetry include Z(N) models with a complex magnetic field, the chiral Potts model and the anisotropic next-nearest-neighbour Ising model. Quantum many-body problems with a non-zero chemical potential have a natural PT-symmetric representation related to the sign problem. Two-dimensional quantum chromodynamics with heavy quarks at non-zero chemical potential can be solved by diagonalizing an appropriate PT-symmetric Hamiltonian.

Effect of hetastarch bolus in trauma patients requiring emergency surgery.

UNLABELLED: If blood products are not available, current military guidelines recommend a hetastarch bolus (HEX, Hextend 6% hetastarch in lactated electrolyte buffer, www. hospira.com) for initial treatment of hypovolemic shock in the field. We previously reported that a HEX bolus plus standard of care (SOC = crystalloid plus blood products) was safe during initial resuscitation in 1714 trauma patients. This study tests the hypothesis that HEX+SOC is more effective than SOC alone for volume expansion in trauma patients requiring urgent operation. METHODS: From July 2009 to August 2010, the records from all adults who required emergency surgery within 4 hours of admission were screened for a retrospective cohort observational study. Burns, and those with primary neurosurgical or orthopedic indications, were excluded. The study population was comprised of 281 patients with blunt (n = 72) or penetrating (n = 209) trauma; 141 received SOC and 140 received SOC+HEX in the emergency room only (ER, n = 81) or the ER and operating room (OR, n = 59). Each case was reviewed with waiver of consent. RESULTS: After penetrating injury, with SOC, the injury severity score was 17 and mortality was 12%; the corresponding values in the HEX(ER) and HEX(OR) groups were 19?21 and 8%, but these apparent differences did not reach significance. However, in patients receiving HEX, initial heart rate was higher, base deficit was lower, and hematocrit was lower (consistent with relative hypovolemia), even though blood product requirements were reduced, and urine output was greater (all p < 0.05). These effects were absent in patients with blunt trauma. Platelet consumption was higher with HEX after either penetrating (p = 0.004) or blunt trauma (p = 0.045), but coagulation tests were unchanged. CONCLUSION: HEX is safe for initial resuscitation in young patients who required urgent operation after penetrating trauma, but there was no apparent effect after blunt trauma. A bolus of HEX reduced transfusion requirements without inducing coagulopathy or causing renal dysfunction, but a randomized controlled trial is necessary to eliminate the possibility of selection bias.

Emergent cricothyroidotomies for trauma: training considerations.

BACKGROUND: Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) physician training. We hypothesized that although most cricothyroidotomies for trauma occur in the emergency department (ED), they are usually performed by surgeons. METHODS: We conducted a retrospective analysis of all emergent cricothyroidotomies for trauma presentations performed at 2 large level I trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of injury and patient demographics were examined. RESULTS: Fifty-four cricothyroidotomies were analyzed. Patients had a mean age of 50 years, 80% were male, and 90% presented as a result of blunt trauma. The most common primary operator was a surgeon (n = 47, 87%), followed by an emergency medical services (EMS) provider (n = 6, 11%) and an EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared with in-hospital procedures (P < .0001). CONCLUSIONS: (1) Prehospital cricothyroidotomy results in serious complications. (2) Despite the ubiquitous presence of EM physicians in the ED, all cricothyroidotomies were performed by a surgeon, which may present opportunities for training improvement.

Heart rate variability is an independent predictor of morbidity and mortality in hemodynamically stable trauma patients.

BACKGROUND: Reduced heart rate variability (HRV) reflects autonomic dysfunction and can triage patients better than routine trauma criteria or vital signs. However, there is questionable specificity and no consensus measurement technique. The purpose of this study was to analyze whether factors that alter autonomic function affect the specificity of HRV for assessing traumatic injury. METHODS: We evaluated 216 hemodynamically stable adults (3:1 M:F; 97:3 blunt:penetrating; age 49 years ± 1 year, mean ± standard error) undergoing computed axial tomography (CT) scan to rule out traumatic brain injury (TBI). All were prospectively instrumented with a Mars Holter system (GE Healthcare, Milwaukee, WI). HRV was determined offline using time domain (standard deviation of normal-normal intervals, root-mean-square successive difference) and frequency domain (very low frequency [VLF], LF, wideband frequency, high frequency [HF], low to HF index ratio) calculations from 15-minute electrocardiogram and correlated with routine vital signs, mortality, TBI, morbidity, length of stay (LOS), and comorbidities. Significance (p ≤ 0.05) was determined using nonparametric analysis, Student's t test, analysis of variance, or multiple logistic regression. RESULTS: VLF alone predicted survival, severity of TBI, intensive care unit LOS, and hospital LOS (all p < 0.05). Beta-blockers or diabetes had no effect, whereas age, sedation, mechanical ventilation, spinal cord injury, and intoxication influenced one or more of the variables with age being the most powerful confounder (all p < 0.05). Except for the Glasgow Coma Scale, no other routine trauma or hemodynamic criteria correlated with any of these outcomes. CONCLUSIONS: Decreased VLF is an independent predictor of mortality and morbidity in hemodynamically stable trauma patients. Other time and other frequency domain variables correlated with some, but not all, outcomes. All were heavily influenced by factors that alter autonomic function, especially patient age.

Pediatric facial trauma: a review of guidelines for assessment, evaluation, and management in the emergency department.

Approximately 22 million children in the United States sustain traumatic injuries every year, the etiologies of which vary with age as well as social and environmental factors. If not managed properly, these injuries can have a significant impact on future growth and development. Evaluation of facial injuries presents a unique diagnostic challenge in this population, as differences from adult anatomy and physiology can result in vastly different injury profiles. The increased ratio of the cranial mass relative to the body leaves younger patients more vulnerable to craniofacial trauma. It is essential that the treating physician be aware of these variations to properly assess and treat this susceptible and fragile patient population and ensure optimal outcomes. This article reviews the proper emergency department assessment and treatment of facial fractures in the pediatric population as well as any associated injuries, with particular emphasis on initial patient stabilization, radiological evaluation, and therapeutic options.

Bispectral index to monitor propofol sedation in trauma patients.

BACKGROUND: This study tested the hypothesis that the bispectral index (BIS) is reliable relative to clinical judgment for estimating sedation level during daily propofol spontaneous awakening trials (SATs) in trauma patients. METHODS: This was a prospective observational trial with waiver of consent conducted in the intensive care unit of Level I trauma center in 94 mechanically ventilated trauma patients sedated with propofol alone or in combination with midazolam. BIS, Richmond Agitation Sedation Scale (RASS), electromyography, and heart rate variability, as a test of autonomic function, were measured for 45 minutes during daily SATs. Data were evaluated with analysis of variance, linear regression, and nonparametric tests. RESULTS: The BIS wave form coincided almost exactly with propofol on/off. Steady-state BIS correlated with RASS (p < 0.0001) and with propofol dose (p < 0.0001), but the strengths of association were relatively low (all r(2) < 0.5). BIS wave form was not altered by age, heart rate, or heart rate variability and was similar with propofol alone or propofol plus midazolam, but the presence of brain injury or the use of paralytics shifted the curve downward (both p < 0.001). The overall test characteristics for BIS versus RASS without neuromuscular blockade were sensitivity: 90% versus 77% (p = 0.034); specificity: 90% versus 75% (p = 0.021); positive predictive value: 90% versus 76% (p = 0.021), and negative predictive value: 90% versus 76% (p = 0.021). CONCLUSIONS: In the first trial in trauma patients and largest trial in any surgical population, the (1) BIS was reliable and has advantages over RASS of being continuous and objective, at least during a propofol SAT; (2) BIS interpretation remains somewhat subjective in patients receiving paralytic agents or with traumatic brain injury.

Quark confinement and the renormalization group.

Recent approaches to quark confinement are reviewed, with an emphasis on their connection to renormalization group (RG) methods. Basic concepts related to confinement are introduced: the string tension, Wilson loops and Polyakov lines, string breaking, string tension scaling laws, centre symmetry breaking and the deconfinement transition at non-zero temperature. Current topics discussed include confinement on R(3)×S(1), the real-space RG, the functional RG and the Schwinger-Dyson equation approach to confinement.

Emergency department assessment and management of facial trauma from war-related injuries.

Facial trauma related to combat injury is of increasing prevalence and complex in nature when associated with the multiply injured trauma victim. Although rarely life-threatening, the treating physician must be aware of the presence of facial trauma and its associated injuries to seamlessly treat the combat casualty in accordance to the Advanced Trauma Life Support protocol while maintaining the armed forces' ultimate goals of returning "the greatest possible number of soldiers to combat and the preservation of life, limb and eyesight in those who must be evacuated." To this end, the treating physician must maintain a high index of suspicion for injury and have various maneuvers available to handle immediate threats to life, limb, or sight. This article will review the proper emergency department assessment and management of prevalent injuries associated with war-related facial trauma.

Predeployment mass casualty and clinical trauma training for US Army forward surgical teams.

Since the beginning of the program in 2002, 84 Forward Surgical Teams (FSTs) have rotated through the Army Trauma Training Center (ATTC) at the University of Miami/Ryder Trauma Center including all those deployed to Iraq and Afghanistan. The purpose of this study was to provide the latest updates of our experience with FSTs at the ATTC. Before deployment, each FST participates in a 2-week training rotation at the ATTC. The rotation is divided into 3 phases. Phase 1 is to refresh FST knowledge regarding the initial evaluation and management of the trauma patient. Phase 2 is the clinical phase and is conducted entirely at the Ryder Trauma Center. The training rotation culminates in phase 3, the Capstone exercise. During the Capstone portion of their training, the entire 20-person FST remains at the Ryder Trauma Center and is primarily responsible for the evaluation and resuscitation of all patients arriving over a 24-hour period. Subject awareness concerning their role within the team improved from 71% to 95%, indicating that functioning as a team in the context of the mass casualty training exercise along with clinical codes was beneficial. The clinical component of the rotation was considered by 47% to be the most valuable aspect of the training. Our experience strongly suggests that a multimodality approach is beneficial for preparing a team of individuals with minimal combat (or trauma) experience for the rigors of medical care and triage on the battlefield. The data provided by participants rotating through the ATTC show that through clinical exposure and simulation over a 2-week period, FST performance is optimized by defining provider roles and improving communication. The mass casualty training exercise is a vital component of predeployment training that participants feel is valuable in preparing them for the challenges that lay ahead.

Incidence and outcomes of extremity soft-tissue sarcomas in children.

BACKGROUND: We studied the outcomes of pediatric extremity tumors on a population scale. METHODS: The Surveillance, Epidemiology, and End Results database (1973-2006) was queried for all patients under 20 y of age. RESULTS: Overall, 1175 patients were identified. The median age at diagnosis was 12 y, but most patients were ≥10 y of age (72%, n = 842). Most tumors were non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) (79%, n = 879). The most common tissue of origin was muscle (43%, n = 474). Most rhabdomyosarcoma (RMS) (n = 220) were alveolar type (n = 140). Most patients presented with local disease (64%, n = 699), and underwent surgical intervention (88%, n = 1027), but did not have radiotherapy (62%, n = 710). RMS was more likely to present in younger children (P < 0.001) and with distant disease (P < 0.001). Older patients were more likely to receive radiotherapy than infants (P < 0.001). Overall 5-y survival was 79%. RMS had significantly worse 5-y survival (56% versus 85% for NRSTS, P < 0.001). Surgical intervention was associated with higher 5-y survival (84% versus 48%, P < 0.001). Radiotherapy was associated with worse 5-y survival (74% versus 83%, P = 0.002). Multivariate analysis identified RMS (HR 2.20, P < 0.001), nerve and muscle (not synovial sarcoma) tissue of origin (HR 2.26, P = 0.002, and HR 1.59, P = 0.036), regional or distant disease (HR 1.65, P = 0.011, and HR 5.96, P < 0.001, respectively), and lack of surgical intervention (HR 2.20, P < 0.001) as independent predictors of poor outcome. CONCLUSIONS: Extremity sarcomas are most common in older children. RMS is more common in younger children, but is associated with lower survival, and is an independent prognostic indicator of mortality.

First report on safety and efficacy of hetastarch solution for initial fluid resuscitation at a level 1 trauma center.

BACKGROUND: For logistics, the US Army recommends Hextend (Hospira; 6% hetastarch in buffered electrolyte, HET) for battlefield resuscitation. To support this practice, there are laboratory data, but none in humans. To test the hypothesis that HET is safe and effective in trauma, we reviewed our first 6 months of use at a civilian level 1 trauma center. STUDY DESIGN: From June 2008 to December 2008, trauma patients received standard of care (SOC) +/- 500 to 1,000 mL of HET within 2 hours of admission at surgeon discretion. Each case was reviewed, with waiver of consent. RESULTS: There were 1,714 admissions; 805 received HET and 909 did not. With HET versus SOC, overall mortality was 5.2% versus 8.9% (p = 0.0035) by univariate analysis. Results were similar after penetrating injury only (p = 0.0016) and in those with severe injury, defined by Glasgow Coma Scale <9 (p = 0.0013) or Injury Severity Score >26 (p = 0.0142). After HET, more patients required ICU admission (40.9% vs. 34.5%; p = 0.0334) and transfusions of blood (34.4% vs. 20.2%; p = 0.0014) or plasma (20.7% vs. 12.2%; p = 0.0251), but there were no treatment-related differences in prothrombin time or partial thromboplastin time. The 24-hour urine outputs and requirements for blood, plasma, and other fluids were similar. However, increased early deaths with SOC implicate possible selection bias. If that factor was controlled for with multivariate analysis, the same trends were present, but the apparent treatment effects of HET were no longer statistically significant. CONCLUSIONS: In the first trial to date in hemodynamically unstable trauma patients, and the largest trial to date in any population of surgical patients, initial resuscitation with HET was associated with reduced mortality and no obvious coagulopathy. A randomized blinded trial is necessary before these results can be accepted with confidence.

A review of ureteral injuries after external trauma.

INTRODUCTION: Ureteral trauma is rare, accounting for less than 1% of all urologic traumas. However, a missed ureteral injury can result in significant morbidity and mortality. The purpose of this article is to review the literature since 1961 with the primary objective to present the largest medical literature review, to date, regarding ureteral trauma. Several anatomic and physiologic considerations are paramount regarding ureteral injuries management. LITERATURE REVIEW: Eighty-one articles pertaining to traumatic ureteral injuries were reviewed. Data from these studies were compiled and analyzed. The majority of the study population was young males. The proximal ureter was the most frequently injured portion. Associated injuries were present in 90.4% of patients. Admission urinalysis demonstrated hematuria in only 44.4% patients. Intravenous ureterogram (IVU) failed to diagnose ureteral injuries either upon admission or in the operating room in 42.8% of cases. Ureteroureterostomy, with or without indwelling stent, was the surgical procedure of choice for both trauma surgeons and urologists (59%). Complications occurred in 36.2% of cases. The mortality rate was 17%. CONCLUSION: The mechanism for ureteral injuries in adults is more commonly penetrating than blunt. The upper third of the ureter is more often injured than the middle and lower thirds. Associated injuries are frequently present. CT scan and retrograde pyelography accurately identify ureteral injuries when performed together. Ureteroureterostomy, with or without indwelling stent, is the surgical procedure of choice of both trauma surgeons and urologists alike. Delay in diagnosis is correlated with a poor prognosis.

Heart rate variability as a triage tool in patients with trauma during prehospital helicopter transport.

BACKGROUND: Prehospital triage of patients with trauma is routinely challenging, but more so in mass casualty situations and military operations. The purpose of this study was to prospectively test whether heart rate variability (HRV) could be used as a triage tool during helicopter transport of civilian patients with trauma. METHODS: After institutional review board approval and waiver of informed consent, 75 patients with trauma requiring prehospital helicopter transport to our level I center (from December 2007 to November 2008) were prospectively instrumented with a 2-Channel SEER Light recorder (GE Healthcare, Milwaukee, WI). HRV was analyzed with a Mars Holter monitor system and proprietary software. SDNN (standard deviation [SD] of the normal-to-normal R-R interval), as an index of HRV, was correlated with prehospital trauma triage criteria, base deficit, seriousness of injury, operative interventions, outcome, and other data extracted from the patients' medical records. There were no interventions or medical decisions based on HRV. Data were excluded only if there was measurement artifact or technical problems with the recordings. RESULTS: The demographics were mean age 47 years, 63% men, 88% blunt, 25% traumatic brain injury, 9% mortality. Prehospital SDNN predicted patients with base excess < or = -6, those defined as seriously injured and benefiting from trauma center care, as well as patients requiring a life-saving procedure in the operating room. No other available data, including prehospital en-route vital signs, predicted any of these. The sensitivity, specificity, positive predictive value, and negative predictive value were 80%, 75%, 33%, 96%, respectively, with and an overall accuracy of 76% for predicting a life-saving intervention in the operating room. CONCLUSIONS: This is the first demonstration that prehospital HRV (specifically SDNN) predicts base excess and operating room life-saving opportunities. HRV triages and discriminates severely injured patients better than routine trauma criteria or en-route prehospital vital signs. HRV may be a useful civilian or military triage tool to avoid unnecessary helicopter evacuation for minimally injured patients. A prospective, randomized trial in a larger patient population is indicated.

Surgery does not adversely affect survival in primary gastrointestinal lymphoma.

OBJECTIVE: To evaluate the impact of surgery on gastrointestinal lymphoma. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried from 1973 to 2005. RESULTS: A total of 17,222 cases of PGIL were identified. The overall incidence of PGIL was approximately 1.505 cases per 100,000. A significantly increasing incidence for PGIL was observed (APC = +4.67, P < 0.05). In the cases for which treatment data was available, resection occurred in roughly half of the patients. In univariate analysis, surgical extirpation did not improve survival (47 months vs. 76 months, P < 0.001), while radiation treatment improved median survival (77 months vs. 59 months, P < 0.001). Multivariate analysis revealed increasing age and male gender as independent predictors of decreased overall survival. Tumor location also was a significant predictor of outcome. Large B-cell lymphoma type PGIL had a poorer prognosis than marginal zone B-cell lymphoma. By multivariate analysis, surgery was not found to increase the risk of death (HR = 0.99). CONCLUSIONS: No associated survival benefit for surgery in the treatment in gastrointestinal lymphoma was observed. Determination of lymphoma should preclude surgical resection. Nonetheless, inadvertent extirpative surgery or in association with perforation does not appear to increase mortality.