Impact of a formal trauma program on a small rural hospital in Mississippi.

BACKGROUND: Since Mississippi is largely rural, most of the initial care given to trauma patients is at small community hospitals. This study examined the impact of the institution of a formal trauma program on trauma care at such a hospital. METHODS: All trauma cases at a single institution during 1998 were retrospectively analyzed. Cases were stratified into two groups, which depended on whether trauma care was given before or after institution of the trauma program. Various parameters were evaluated and compared. RESULTS: The disposition of trauma cases changed after institution of a formal protocol: both transfers to trauma centers and hospital admissions decreased, while the number of cases cleared in the emergency department (ED) increased. The percentage of cases inappropriately managed also decreased. CONCLUSIONS: Institution of a formal trauma program increased the efficiency of resource utilization and improved the level of care received by trauma patients.

The role of the rural surgeon as endoscopist.

As the number of physicians and surgeons practicing in rural communities decreases the roles of those physicians must necessarily expand to meet the needs of the community. Nowhere is this more apparent than in the field of endoscopy. This analysis was undertaken to examine the role of the rural general surgeon in the performance of endoscopy and the outcomes of endoscopic procedures in the hands of the general surgeon. This is a retrospective analysis of all endoscopic procedures performed at a single institution between July 1, 1996 and December 31, 1998. Data were stratified on the basis of type of procedure, indication, and findings. The patient group was a consecutive sample of all patients during the study period referred to the single general surgeon at a small acute-care hospital in rural east-central Mississippi for endoscopic procedures. All patients met accepted criteria for the proposed procedure. Patients underwent either esophagogastroduodenoscopy, colonoscopy, or diagnostic laparoscopy. Endoscopy comprised 24 per cent of all cases performed by the surgeon. Upper endoscopy accounted for 65 per cent of the total, colonoscopy for 29 per cent, and diagnostic laparoscopy for 6 per cent. Positive findings of significance were found in 75 per cent of endoscopic cases overall. Endoscopy comprises a significant proportion of the general surgeon's practice in the rural setting. With good patient selection in this setting the positive-finding rate is very high.

Patterns of surgical practice in a small rural hospital.

BACKGROUND: A significant proportion of the population in the United States lives in rural areas, yet these areas are traditionally underserved in terms of surgical and other medical specialists. As a result, the operative experience of surgeons practicing in rural areas is different than that of surgeons operating in urban centers. This study was undertaken with the goal of delineating the surgical experience in a small hospital in rural Mississippi and correlating that with the training of surgical residents. STUDY DESIGN: The operative experience between July 1, 1996, and December 31, 1998, of a single surgeon at Newton Regional Hospital in rural Newton, MS, was evaluated. All cases were classified as either traditional-general-surgical or nongeneral-surgical; the latter category was further divided into endoscopy, gynecology, orthopedic, ENT, urology, and vascular. RESULTS: A total of 1,153 operations was performed by the one-man surgical department during the study period. Traditional general surgery patients accounted for 50.6% of the total, endoscopy totalled 21%, and vascular patients totalled 2.6%. The remaining 25.8% were stratified as follows: gynecology, 4.3%; orthopedics, 10.3%; ENT, 3.5%; and urology, 7.7%. CONCLUSIONS: The operative experience in a small rural hospital is significantly different from that at larger urban centers and is also markedly different from the experience of residents in major teaching centers. This would suggest the need to broaden the experience of graduating residents intending to practice in a rural setting.

Breast cancer in young patients.

BACKGROUND: Breast cancer in a young person is considered by many to be a rare and very aggressive disease. Theories regarding the aggressiveness of the disease are varied. This study was undertaken in an attempt to help formulate guidelines regarding screening for and treatment of breast cancer in the young patient. PATIENTS AND METHODS: A retrospective review was undertaken of 81 breast cancer patients aged < or = 35 years who underwent definitive surgical treatment. All patients were treated at a single institution. RESULTS: Overall 5- and 10-year survival rates were 65% and 49%, respectively. In patients with disease localized to the breast, 5- and 10-year rates were 89% and 78%, respectively. There was no significant difference in survival with respect to age or date of diagnosis, nor was there a difference in cancer stage distribution. The only major determinant of survival was stage at the time of diagnosis. CONCLUSIONS: We conclude that young age does not seem to be directly related to the "aggressiveness" or "virulence" of breast cancer, especially among patients with localized disease. These results underscore the need for aggressive and early treatment of these patients. The improved survival with early detection is a valid argument for careful screening, even among very young patients.

Role of computed tomography scan in evaluating the widened mediastinum.

Thirty-eight blunt trauma patients with a suspicion of thoracic aortic injury were assessed by computed tomography (CT) scan, aortography, and chest x-ray. Twenty-eight of the 38 patients had widened mediastinum by chest x-ray; four of 13 CT scans were abnormal. No patient with a negative CT scan had aortic injury by aortogram. A normal, non-dynamic CT scan of the chest should influence one's decision-making in the need for aortography.

Prediction of outcome in "resectable" esophageal carcinoma.

A retrospective review was performed of 51 patients with esophageal carcinoma, deemed "resectable" by preoperative workup (e.g., CT scan, barium swallow), who presented to Hahnemann University Hospital between 1980 and 1991. This represented 21.8% of the total number of patients (234) with esophageal cancer who presented during that time period. At exploration, only 21 of the 51 patients (41%, or 9% overall) were truly resectable; 59% had more extensive disease than was appreciated preoperatively and that precluded resection for cure. Of the 21 patients resected for cure, 24% were alive at two years and only 5% were alive at 3 years. Neither age, gender, tumor type nor location in the esophagus significantly affected overall survival. Furthermore, none of these parameters, taken as independent variables, were able to predict true resectability at the time of operation. We conclude that preoperative assessment of resectability, even in those patients who appear to be good candidates for cure, remains imprecise at best. Given an operative mortality rate of 6-8% (in most series) and an overall 3- to 5-year survival rate of less than 10% (even in patients thought to have had curative resections), we reinforce the fact that meticulous patient selection and multimodality management strategies remain the keys to making any impact on this disease.

Revascularized diabetic limbs: positional changes in regional perfusion index.

We measured pre- and postoperative ankle:brachial index (ABI), regional perfusion index (RPI = foot/chest transcutaneous oxygen tension [TcpO2]), and variation in RPI with limb elevation in 22 ischemic lower extremities of 20 patients to compare ABI and RPI measurements for quantifying limb perfusion and analyze perioperative positional changes in RPI. Measurements were compared, using t tests, with all limbs grouped according to severity of clinical ischemia and, again, according to presence or absence of diabetes. Preoperative mean and mean post-revascularization increases in ABI values ranged from 0.27 to 0.48 and 0.40 to 0.54, respectively; corresponding RPI values ranged from 0.18 to 0.45 and 0.48 to 0.60, respectively. Pre- and postoperative decreases in RPI with elevation ranged from 0.07 to 0.11 and 0.11 to 0.23, respectively. ABI and RPI values were equally effective in assessing clinical ischemia preoperatively and increased perfusion postoperatively, regardless of degree of ischemia or diabetes. Upon elevation, all limbs exhibited larger decrements in blood flow to the skin postoperatively compared to preoperatively, as estimated by RPI. However, postoperative positional decrease in RPI was greater in diabetics compared with nondiabetics (0.23 +/- 0.12 vs 0.12 +/- 0.06; P < 0.05), suggesting postoperative elevation of diabetic limbs with ischemic skin lesions may be unadvisable.

Predictors of pulmonary complications in blunt chest trauma.

A retrospective review was performed of 98 patients admitted to a Level I Trauma Center between July 1989 and December 1990 with a diagnosis of blunt chest trauma. Of these patients, 49% suffered either immediate or delayed complications. Immediate complications included hemothorax or pleural effusion in 21.4%, pneumothorax in 36.7%, and ruptured diaphragm in 2%. Delayed complications occurred in 29.6% of patients overall; these included pulmonary contusion in 33.7%, pneumonia in 5.1%, and pulmonary embolus in 1.0%. Both initial Trauma Score (TS) and the Injury Severity Score (ISS) were predictive of mortality. The mortality rate was significantly greater in patients with a TS < or = 13-30.2% of these patients died of their injuries as opposed to 1.9% of those with a TS > 13. Similarly, 19.7% of patients with an ISS > or = 16 died, while all patients with an ISS < 16 survived. These differences were statistically significant (p < 0.001 and p < 0.05, respectively). Neither TS nor ISS, however, was predictive of either immediate or delayed complications. Even with a TS > 13, 47.2% of patients suffered complications; 80% of these patients had delayed complications. Similarly, 51.8% of patients with ISS < 16 had complications. Statistically, neither TS nor ISS could be used to predict complications, regardless of the reference value chosen for TS or ISS. Therefore, it is imperative that all patients with blunt trauma be considered at risk for secondary complications, even those with "favorable" TS or ISS.

Factors influencing survival in infiltrating lobular carcinoma of the breast.

Seventy cases of infiltrating lobular (IL) carcinoma of the breast presenting to Hahnemann University Hospital between 1965 and 1990 were reported. This comprised 2.4 per cent of the total number of breast cancer cases during that time period. Fifty-seven of these tumors were pure IL carcinoma, while 13 had both IL and infiltrating ductal characteristics. Two-year, 5-year, and 10-year survival rates were not influenced by stage at the time of presentation, histology, nor operation performed. Though a statistically significant trend toward breast conservation surgery was documented over time, there was no significant relationship between operation performed and survival. This was true for both localized and nodal-metastatic disease. Overall survival was essentially equivalent to that reported for infiltrating ductal carcinoma.

Major long-term complications in 1,422 permanent venous access devices.

A retrospective review was undertaken of 1,422 permanent venous access devices (PVADs) implanted from 1989 to 1991 at Hahnemann University Hospital. This included 730 single-lumen Hickman catheters, 368 double-lumen Hickman catheters, 307 single-lumen Portacath infusion ports, and 17 double-lumen Portacath infusion ports. Indications for placement were as follows: antibiotics in 28%; chemotherapy in 51%; hyperalimentation in 4%; intravenous fluids in 4%; hemodialysis in 3%; and undocumented indications in 10%. There were 60 PVADs removed and/or replaced prior to the completion of intended therapy (4% overall). Indications for removal were catheter infection in 1% of cases and catheter malfunction in 3% of cases. The percentage of Portacath infusion ports removed was significantly greater than the percentage of Hickman catheters that were removed (p < 0.001). However, there was no significant relationship between catheter infection or the malfunction rate, and the number of lumens, initial indication for placement, or number of catheters placed. Life-threatening complications associated with PVAD insertion occurred in fewer than 1% of cases. The insertion of PVADs is a safe and efficient mode of long-term venous access.

Myxoid chondrosarcoma of the abdominal aorta.

In this case report we present a 64 year old man who underwent resection of his infrarenal abdominal aortic aneurysm. Thrombus of unusual color, texture and consistency was noted within this aneurysm which upon histopathologic analysis had the characteristics of a myxoid chondrosarcoma. Primary myxoid chondrosarcoma of the abdominal aorta is very rare and to our knowledge this report represents the first recorded case. The clinical presentation of our patient was dominated by hypertension and severe lower extremity claudication associated with microembolization to the left fourth toe.

The "learning curve" in the performance of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy was successfully performed on 23 of the first 28 patients in whom this was attempted (82.1%). After the first ten cases, the success rate increased to 94.4%. There was only one major complication which prolonged hospital stay but did not require re-operation. Operative time decreased markedly from a mean of 160 minutes for the first ten cases to 61 minutes for the remainder. This increase in operative speed was not accompanied by an increase in complications, in spite of a liberalization of patient selection criteria. It is clear that a steep "learning curve" exists for this procedure and must be recognized and appreciated if laparoscopic cholecystectomy is to become a safe and efficient procedure.

Thrombolytic therapy before reconstructive vascular procedures for acute or subacute graft occlusions.

The purpose of this study was to evaluate the efficacy of direct intra-arterial Urokinase infusions prior to anticipated adjunctive reconstructive vascular procedures in 16 patients with 24 acutely or subacutely occluded lower extremity grafts (22 femoropopliteal, 2 femorotibial). Complete thrombolysis was achieved angiographically in 18 (75%) of 24 graft occlusions. Neither age, gender, current smoking, diabetes mellitus, hypertension, nor coronary arterial disease were significantly associated with complete thrombolysis. The only significant factor related to complete thrombolysis was the duration of the occlusion prior to lytic treatment (p < 0.05). Adjunctive reconstructive procedures were performed for eleven of 18 cases in which complete thrombolysis was achieved. These included nine percutaneous transluminal balloon angioplasties (at eight distal and one proximal anastomotic stenoses) and two bypass operations (femoropopliteal). The remaining seven cases had no adjunctive procedure. These 18 cases were examined for patency rates during nine months of follow-up. Six (54%) of 11 cases with adjunctive reconstructive vascular procedures remained patent, while one (14%) of seven cases with no adjunctive procedure remained patent (p = 0.1). Six (25%) of 24 cases resulted in incomplete thrombolysis. Vascular procedures following these cases included two bypass operations, three amputations and one sympathectomy. This study suggests that complete thrombolysis of acutely occluded grafts might have minimized subsequent reconstructive procedures. Identification of correctable lesions and adjunctive reconstructive procedures performed following complete thrombolysis may be the important factors related to long-term patency.

Changing patterns in colorectal carcinoma: a 25-year experience.

The pattern of colorectal carcinoma, especially with respect to stage and tumor location, has changed noticeably over the past 25 years. During that time period, 1,959 patients came to Hahnemann University Hospital with colorectal cancer, 1,584 of whom were reviewed in this study. There was a significant relationship between extent of disease and date of diagnosis, with the trend being toward decreasing stage at the time of diagnosis. In addition, there has been a demonstrable "rightward shift" in tumor location, especially over the past 15 years. This has been accompanied by a slight increase in the detection of rectal lesions as well. The trend toward earlier and more proximal lesions is likely due in large part to the increasingly widespread use of surveillance colonoscopy and sigmoidoscopy.

The changing role of the surgeon in the management of cancer in the university setting and its impact on resident training.

A retrospective review was performed of 22,168 cancer cases registered by the Tumor Registry between 1965 and 1990. Eighty-six percent of these cases involved solid tumors; this number remained fairly constant throughout the study period. There was a significant trend toward more advanced disease at the time of presentation, most marked in the last 10 years; prior to 1980, 63.7% had localized or in situ cancer as opposed to only 49.4% since 1980 (P < 0.001). This suggested that more advanced cases were being submitted for treatment. As expected, more disseminated disease at the time of presentation was coupled with an overall decrease in the number of cases in which surgery comprised part of the treatment: 43.6% prior to 1980 vs. 38.1% after 1980. This trend has reversed, however, in the last 5 years. Though the number of cases in which surgery was the only treatment modality remained constant prior to and after 1985 (26.8% and 27.1%, respectively), the number of cases in which surgery was part of a multimodality treatment plan significantly increased (39.9% prior to 1985; 45.3% after 1985). This was coupled with a significant decrease in the number of cases treated with nonsurgical modalities alone (60.1% prior to 1985; 54.7% after 1985). Therefore, not only has the surgeon been called upon to operate on more advanced disease for cure in the last 5 years, but he or she has also become increasingly involved in multimodality treatment. Since 40.4% of university departments of surgery (as of 1990) did not provide specific training in surgical oncology, it is suggested that these departments reevaluate the objectives of their educational programs in view of the changing, increasingly complex role of the surgeon in the multidisciplinary approach to the care of the cancer patient.

Significance of wall thickness in symptomatic gallbladder disease.

One hundred cases of patients who underwent urgent cholecystectomy after presenting with symptoms of acute or subacute gallbladder disease were retrospectively reviewed. Sixty patients had pathologically proved acute cholecystitis, and 40 had chronic cholecystitis alone. One patient had an incidental gallbladder carcinoma, and four had global gangrene of the gallbladder. Focal ischemia, transmural hemorrhage, or focal necrosis (indicating more severe disease) was present in 19 patients. Fifty-four percent of patients had thin-walled gallbladders. Among patients with more severe acute disease, 56% had thin walls. Conversely, 24% of thin-walled gallbladders and 22% of thick-walled gallbladders had evidence of focal necrosis or gangrene. We conclude that gallbladder wall thickness, although demonstrable on preoperative ultrasound examination in all patients, does not correlate directly with severity of disease or pathologic findings.

Thrombolytic therapy of synthetic graft occlusions before vascular reconstructive procedures.

The objective of this study was to evaluate the impact of thrombolysis of synthetic grafts before urgent vascular reconstruction. In 29 patients, 41 thrombosed synthetic grafts that underwent intraarterial thrombolysis were studied. The cases were divided into three groups: group I--complete thrombolysis followed by reconstruction; group II--complete thrombolysis alone; and group III--incomplete lysis requiring reconstruction or sympathectomy. Follow-up ranged from 1 to 556 days (mean: 149 days). Kaplan-Meier analysis was used to determine patency and limb salvage rates. One-year patency and limb salvage rates were 53% and 95%, 34% and 67%, and 38% and 48%, respectively, for groups I, II, and III. Eighteen complications occurred in 16 of the 41 (39%) episodes. One patient died of intracranial hemorrhage. The best results were achieved when complete lysis was followed by appropriate reconstruction. Patency was equally poor in complete thrombolysis alone and reconstructions required by incomplete thrombolysis. Limb salvage was better after complete thrombolysis, regardless of the appropriate reconstruction.

Changing patterns in the predisposition for amputation of the lower extremities.

The purpose of this study was to evaluate and determine the role of diabetes and other common predisposing factors in amputation of the lower extremities. A retrospective review of 110 patients with peripheral vascular disease who underwent amputation between 1987 and 1990 at Hahnemann University Hospital (Philadelphia, PA) was performed. Patients who underwent amputations for trauma or cancer were excluded from this analysis. The patients were divided into four groups according to the site of amputation: Above Knee (n = 43), Below Knee (n = 26), Foot (n = 7) and Transmetatarsal (n = 34). The mean age was 60 years. Fifty-five patients (51%) were white. Sixty-four patients (58%) were men. Twenty-nine patients (26%) were cigarette smokers; sixteen smokers (55%) had above-knee amputation. Thirty-five patients (32%) had previous vascular surgery of the lower extremities. The combination of diabetes and hypertension was present in 40 patients (36%). When either diabetes or hypertension alone was present in a patient, hypertension, not diabetes, was more commonly the dominant underlying medical condition in patients with amputation (32 hypertension-alone patients vs. 10 diabetes-alone patients). The high frequency of hypertension suggests that enhanced control of this disease may affect peripheral vascular disease and related amputations in the future.

Clinical experience with polytetrafluoroethylene (PTFE) in the aortobifemoral position.

Between 1981 and 1990, 18 patients (mean age 66.0 years) had aortobifemoral bypass with polytetrafluoroethylene (PTFE) bifurcated grafts. Twelve patients (66.7%) were treated for aortoiliac occlusive disease, 5 patients (27.8%) for abdominal aortic aneurysms and one patient (5.6%) had surgery for hypoplastic aortic syndrome. The authors' overall complication rate was 16.7 per cent and included formation of an anastomotic pseudoaneurysm (1/18, 5.6%), graft infection (1/18, 5.6%), and graft thrombosis (1/18, 5.6%). Sixteen patients were followed for a mean period of 41.4 months. In this subgroup of patients the patency rate was 93.8 per cent. The authors conclude that the PTFE bifurcated graft is a suitable conduit for use in aortobifemoral bypass surgery.

Percutaneous transluminal angioplasty of an occluded distal splenorenal shunt.

A distal splenorenal (Warren) shunt was performed on a 39-year-old female with bleeding esophageal varices secondary to portal hypertension and cirrhosis. On the twelfth postoperative day, however, she rebled, and angiography revealed that the shunt was occluded. Using a percutaneous approach, successful balloon angioplasty and recanalization was performed. The patient did well and was discharged without further bleeding. Percutaneous transluminal angioplasty (PTA) appears to be effective in dilating occluded splenorenal shunts, obviating a second surgical procedure in high-risk patients.