Alexis Carrel and His Voyage of Discovery: Miracles and the Spirituality of Healing.

In the era of positivism and anticlericalism of France's Belle Époque, scientist Alexis Carrel stood in stark contrast as one preoccupied with his faith and its relation to scientific scrutiny. Despite his early adult agnosticism, he sought proof of the divine and chose verification of the miraculous cures reported from the shrine at Lourdes, France. It so happened that on his first visit there, he encountered a truly remarkable "cure" of a young woman in the terminal stages of tubercular peritonitis. On a return visit, for the second time, he witnessed the restoration of sight to a blind child. Throughout the rest of his life, Carrel was struck by the proximity of the supernatural to corporeal interactions. He ultimately found a place for his faith as a parallel pathway and not in juxtaposition to the scientific. This paper chronicles Carrel's evolution of belief and reconciliation of faith and science.

Ton That Tung's livers.

Born in the early 20th century, the Vietnamese surgeon Ton That Tung received his medical education in French colonial Indochina at the fledgling l'Ecole de Médecine de Hanoi, the first indigenous medical school in Southeast Asia. The benefactor of a postgraduate position at the medical school, Ton That Tung subsequently obtained his surgical training at the Phù Doãn Hospital in Hanoi and concurrently developed a passion for the study of liver anatomy, pathology, and surgery. His contributions to an understanding of liver anatomy based on meticulous dissection of autopsy specimens antedated and rivaled later work by the famous Western anatomists Couinaud, Healey, Schroy, and others. Ton That Tung's contributions, however, were overshadowed by the intense national struggles of the Vietnamese to establish independent rule and self-governance from the French and by eventual alignment with eastern bloc Communist countries, thus isolating much of his work behind the "Iron Curtain" until well after the end of the Cold War. Nevertheless, Ton That Tung remains a pioneer in liver anatomy and liver surgery. His commitment to surgical science and, more importantly, to the Vietnamese people stands as a tribute to the tireless pursuit of his ideals.

Cause of death from liver metastases in colorectal cancer.

BACKGROUND: Surgically directed therapy for liver metastases from colorectal cancer (CRC) has received substantial attention in the literature as a major focus of treatment for metastatic CRC. It is presumed, but not proven, that liver metastases are a major threat to life. This study examined the course of a cohort of consecutive patients who died with CRC to determine the role played by the presence of liver metastases. METHODS: This is single-institution retrospective observational study involved all patients who died of CRC. Records were examined and imaging studies reviewed to determine the extent of liver and extrahepatic metastases in these patients. Overall survival in patients with and without liver metastases and those in whom liver metastases were thought to contribute to death was determined. RESULTS: After patient exclusions, the study population totaled 121 patients. There were 75 patients (62%) with liver metastases at death. In 40 of 75 (53%) patients, the liver metastases contributed to the patients' death. In 46 of 121 patients (38%), metastatic disease did not include liver metastases. Overall survival in patients with and without liver metastases (median survival 12 vs. 8.5 months, p = 0.089) and in those whose liver metastases did or did not contribute to death (median survival 11.5 vs. 14 months, p = 0.361) was not significant. CONCLUSIONS: The presence of liver metastases seemed to contribute to death in approximately half of the study patients, although there did not appear to be a survival disadvantage in these patients.

Evaluation and treatment of gastric stimulator failure in patients with gastroparesis.

OBJECTIVE: This study evaluates treatment of gastroparesis patients refractory to gastric electrical stimulation (GES) therapy with surgical replacement of the entire GES system. SUMMARY BACKGROUND DATA: Some patients who have symptomatic improvement with GES later develop recurrent symptoms. Some patients improve by simply altering pulse parameter settings. Others continue to have symptoms with maximized pulse parameters. For these patients, we have shown that surgical implantation of a new device and leads at a different gastric location will improve symptoms of gastroparesis. METHODS: This study evaluates 15 patients with recurrent symptoms after initial GES therapy who subsequently received a second GES system. Positive response to GES replacement therapy is evaluated by symptoms scores for vomiting, nausea, epigastric pain, early satiety, and bloating using a modified Likert score system, 0 to 4. RESULTS: Total symptom scores improved for 12 of 15 patients with GES replacement surgery. Total score for the replacement group decreased from 17.3 ± 1.6 to 13.6 ± 3.7 with a difference of 3.6 (P value = .017). This score is compared with that of the control group with a preoperative symptom score of 15.8 ± 3.6 and postoperative score of 12.3 ± 3.5 with a difference of 3.5 (P value = .011). The control group showed a 20.3% decrease in mean total symptoms score, whereas the study group showed a 22.5% decrease in mean with an absolute reduction of 2.2. CONCLUSION: Reimplantation of a GES at a new gastric location should be considered a viable option for patients who have initially failed GES therapy for gastroparesis.

Caution in interpretation of the tumor marker CA 19.9 in patients with obstructive jaundice: illustrative case reports.

BACKGROUND: Carbohydrate antigen (CA) 19.9 is a Lewis blood group oligosaccharide antigen which exists in fixed and soluble forms. The CA 19.9 antigen is synthesized by epithelial cells of the gastrointestinal tract, pancreatic duct, and biliary tree. The CA 19.9 antigen is commonly used as a tumor marker for malignancies of the pancreas and biliary tract. High levels (> 300 U/ml) of antigen have strongly suggested malignant processes. METHODS: Four patients are described with markedly elevated levels of CA 19.9 due to benign calculous disease. RESULTS: Three of four patients underwent endoscopic stone removal followed by cholecystectomy; the fourth patient spontaneously passed stones and had a subsequent cholecystectomy with benign inflammatory pathology. Removal or passage of the obstructing stones produced normalization of the CA 19.9 in each case even with long-term follow-up up to one year. All pathology specimens were interpreted as benign. CONCLUSIONS: Marked elevations of CA 19.9 may be found in benign obstructive disease and should be interpreted with caution until biliary obstruction is relieved.

Surgeon Henry Tonks and the blur of artistry.

The professional career of 20th Century British surgeon and artist Henry Tonks provides a unique perspective into the complex balance of technique, creativity, and empathy necessary to heal both body and soul. For Tonks, the skills of surgery did not suffice to address his intense emotional attachment to his suffering patients. For that reason, he turned to painting as an expression of deeper efforts to demonstrate human suffering to which he was so sensitive and which engulfed him at times in the tragedies of mankind. Nevertheless, his appreciation of the fine details of surgery and surgical manipulations of the body never diminished. His anatomic sketches proved invaluable in reconstructive surgery. Yet, his preference remained to display the entire dimensions of his world through brush and colors. In the process, concern for the personal imperfections of both of his chosen professions enabled Tonks to continually analyze his artistry and to instill that same discipline in his students. This, too, made him a revered teacher and effective interpreter of humanism.

Ectopic liver masquerading as a floating intracaval mass.

Ectopic liver is defined as liver parenchyma situated outside the liver proper with no connection to native hepatic tissue. This rare developmental anomaly is most commonly described as an attachment to the gallbladder with an incidence <0.3%, but it has been reported in other locations within the abdomen and thorax.(2-4) Most cases are found incidentally in asymptomatic patients, but ectopic liver has been known to cause visceral or vascular obstruction.(4,5) Herein we present a unique case of ectopic liver attached by a thin stalk seemingly floating in the suprahepatic inferior vena cava.

First echelon hospital care before trauma center transfer in a rural trauma system: does it affect outcome?

BACKGROUND: Rural trauma has been associated with higher mortality because of a number of geographic and demographic factors. Many victims, of necessity, are first cared for in nearby hospitals, many of which are not designated trauma centers (TCs), and then transferred to identified TCs. This first echelon care might adversely affect eventual outcome. We have sought to examine the fate of trauma patients transferred after first echelon hospital evaluation and treatment. METHODS: All trauma patients transferred (referred group) to a Pennsylvania Level I TC located in a geographically isolated and rural setting during a 68-month period were retrospectively compared with patients transported directly to the TC (direct group). Outcome measures included mortality, complications, physiologic parameters on arrival at the TC, operations within 6 hours of arrival at the TC, discharge disposition from the TC, and functional outcome. Patients with an injury severity score <9 and those discharged from the TC within 24 hours were excluded. RESULTS: During the study period, 2,388 patients were transported directly and 529 were transferred. Mortality between groups was not different: 6% (referred) versus 9% (direct), p = 0.074. Occurrence of complications was not different between the two groups. Physiologic parameters (systolic blood pressure, heart rate, and Glasgow Coma Scale score) at admission to the Level I TC differed statistically between the two groups but seemed near equivalent clinically. Sixteen percent of patients required an operative procedure within 6 hours in the direct group compared with 10% in the referral group (p = 0.001). Hospital and intensive care unit length of stay were less in the referred group, although this was not statistically significant. Performance scores on discharge were equivalent in all categories except transfer ability. Time from injury to definitive care (TC) was 1.6 hours ± 3.0 hours in the direct group and 5.3 hours ± 3.8 hours in the referred group (p < 0.0001). The most common procedure performed at first echelon hospitals was airway control (55% of referred patients). CONCLUSIONS: In this rural setting, care at first echelon hospitals, most (95%) of which were not designated TCs, seemed to augment, rather than detract from, favorable outcomes realized after definitive care at the TC.

The effect of resident duty hour restriction on trauma center outcomes in teaching hospitals in the state of Pennsylvania.

BACKGROUND: Resident duty hour restriction was instituted to improve patient safety, but actual impact on patient care is unclear. We sought to determine the effect of duty hour restriction on trauma outcomes in Level I trauma centers (TCs; surgery residency programs) versus Level II TCs (those with no surgery residency programs) within the state of Pennsylvania, using noninferiority as our hypothesis testing. METHODS: Outcomes (mortality and length of stay [LOS]) were compared in Level II TCs without surgery residencies (n = 7) with Level I TCs (with surgery residencies; n = 14) PRE80 (2001-2003) and POST80 (2004-2007). The subcategories of critically injured patients, Injury Severity Score (ISS) >15, ISS >25, Trauma and Injury Severity Score (TRISS) ≤ 50, Abbreviated Injury Scale (AIS) head/chest/abdomen score >3, age >65 years, mechanism, and shock, functioned as outcome predictors. RESULTS: There was a decrease in mortality overall PRE80 to POST80 for Level I and II TCs. There was a decrease in mortality in Level I TCs POST80 in ISS >15 (16.5% vs. 14.8%, p = 0.0001), AIS (head) score >3 (20.8% vs. 17.8%, p < 0.0001), age >65 years (12.2% vs. 10.7%, p = 0.0013), and blunt mechanism (5.2% vs. 4.6%, p = 0.0004). LOS was reduced in ISS >15, AIS (head) score >3, age >65 years, and penetrating mechanism in Level I TCs POST80. A similar but more profound decrease was also seen in Level II TCs PRE80 and POST80 (ISS >15, 25; AIS (head) score; shock; blunt mechanism; and TRISS ≤ 50). Testing for inhomogeneity identified less-severely injured patients at Level II TCs POST80 compared with Level I TCs in certain subcategories (ISS >15, 25; AIS (head) score; shock; blunt mechanism; and TRISS ≤ 50) regarding mortality and LOS (TRISS >50%). CONCLUSIONS: Decreases in mortality and LOS during the study periods were likely not related to resident work hour restriction but rather to overall improvement in outcomes seen at Level II (no residents) and Level I (residents) TCs. Resident work hour restrictions had no discernible effect on patient care (noninferiority).

Combat Wound Initiative program.

The Combat Wound Initiative (CWI) program is a collaborative, multidisciplinary, and interservice public-private partnership that provides personalized, state-of-the-art, and complex wound care via targeted clinical and translational research. The CWI uses a bench-to-bedside approach to translational research, including the rapid development of a human extracorporeal shock wave therapy (ESWT) study in complex wounds after establishing the potential efficacy, biologic mechanisms, and safety of this treatment modality in a murine model. Additional clinical trials include the prospective use of clinical data, serum and wound biomarkers, and wound gene expression profiles to predict wound healing/failure and additional clinical patient outcomes following combat-related trauma. These clinical research data are analyzed using machine-based learning algorithms to develop predictive treatment models to guide clinical decision-making. Future CWI directions include additional clinical trials and study centers and the refinement and deployment of our genetically driven, personalized medicine initiative to provide patient-specific care across multiple medical disciplines, with an emphasis on combat casualty care.

Pancreas cancer in Mississippi: present challenges and future directions.

Pancreatic cancer remains a deadly disease. Currently, the only hope for cure is surgical resection at an early stage of the disease. However, there is evidence that many individuals do not receive this treatment, perhaps because of health care disparities. Mississippi, because of its socioeconomic composition, has been the focus of concern for health care disparities. In order to determine whether such disparities exist in Mississippi for pancreatic cancer, a retrospective analysis was done from 2000 2006 of case diagnosis, treatment, and mortality from this disease. The Mississippi Cancer Registry, the American College of Surgeons (ACS) National Cancer Data Base (NCDB), and the National Cancer Institute (NCI) Surveillance Epidemiology and End Results (SEER) program were surveyed. Outcomes at all 12 ACS Commission on Cancer (CoC) accredited hospitals within the state were compared to the NCDB nationwide (n=1331 hospitals). In 2006 Mississippi had the highest death rate from pancreas cancer in the nation (12.7/100,000). Age-adjusted incidence by county ranged to a high of 26.91/100,000. Fifty-one percent of patients who died from pancreatic cancer in the state were treated at ACS CoC hospitals. The fate of the other 49% is not known. Of the patients tracked at CoC hospitals, there was essentially no significant difference with respect to age distribution, stage at diagnosis, or first treatment modalities when compared to NCDB nationwide CoC data. There were fewer patients surviving two years with locally advanced disease compared to national figures. Of concern was the large number of patients whose treatment for pancreatic cancer is unknown. It is incumbent on health care providers in the state to develop a system of care for pancreatic cancer that is accessible, inclusive, and comprehensive.

A betrayal of our handiwork: postoperative hemorrhage and the need for reoperation.

Postoperative hemorrhage (PH) that requires reoperation to control bleeding represents a potentially life-threatening and avoidable complication that could have serious implications for recovery. All surgical patients were reviewed who developed PH and required reoperation for control of hemorrhage over a 12-year period, to examine contributing factors possibly related to surgeon misadventure. Of 89,663 operations during this period, there were 1,031 patients (1.2%) who developed PH. Of these, 36 patients required reoperation for control of PH (0.04%), including, general surgery (17), otolaryngologic (9), cardiovascular (9), and gynecologic (1) patients. In 27 general, cardiovascular, and gynecologic patients (29 reoperations), the age ranged from 6 to 91 years. Almost one-half of patients (56%) developing PH were on preoperative anticoagulation. Estimated operative blood loss (EBL) was moderate (EBL = 100-500 mL, 48%). Most patients were normothermic (80%) and normotensive (93%) intraoperatively. The decision to reoperate was not made for at least 8 hours in 55 per cent of patients. At reoperation 10/29 patients were hypotensive. In 20/36 patients (56%) the reoperation note did not identify a single source of bleeding. PH is a distinctly uncommon complication of surgery and often not due to obvious surgeon misadventure. Reoperation for PH is even rarer and embarked upon with reluctance, frequently not yielding a discernible cause for hemorrhage.

Practice patterns in the use of retrievable inferior vena cava filters in a trauma population: a single-center experience.

BACKGROUND: The use of permanent inferior vena cava filters (IVCFs) offers protection against pulmonary embolism (PE) but increases the long-term risk of deep vein thrombosis (DVT) and does not affect long-term mortality. The use of retrievable IVCFs in trauma patients offers the dual advantage of protection against PE during the risk period and the option of filter removal thus avoiding complications of DVT. Despite the safety of removal, it is likely that many of these retrievable filters are not removed. METHODS: This was a retrospective, single-center, observational cohort study at a rural level I trauma center. We sought to investigate the number of patients and the circumstances under which retrievable IVCFs were placed and removed. RESULTS: During a 4-year period, 3,455 trauma patients were admitted and 125 patients had retrievable IVCFs placed (71 therapeutic and 54 prophylactic). The most common indications were traumatic brain and spinal cord injuries (66%). During in-hospital filter use, there were 36 new incidences (29%) of PE (1) and DVT (35). Nine patients died before removal. In 40 patients (32%), removal was attempted, and 32 (26%) retrievable IVCFs were successfully removed and in most patients (76%) within 180 days of insertion. Seventeen patients were transferred out of the area for extended care and lost to follow-up. In 55 patients, the filters were not removed. In 20 patients, the surgeon decided against removal. Thirty patients were transferred to extended care or rehabilitation within the community, but they did not return for removal. Thus, of 108/125 patients with follow-up, 76 patients (70%) did not have their IVCFs removed, and 50 patients did not have their IVCFs removed because of the choice of the surgeon, extended care, or rehabilitation. CONCLUSIONS: The use of retrievable IVCFs, when necessary, produced predictable protection against PE and DVT complications. Despite the opportunity for removal, most patients, in fact, did not have their filters removed, even when posthospital care could be tracked. The practices of the surgeon, the transfer to extended-care facilities, near or far, and the reluctance to remove long-standing IVCFs contributed to the high-retention rate.

The challenges of resident training in complex hepatic, pancreatic, and biliary procedures.

Operations on the liver and pancreas have fallen within the domain of the general surgeon and have been part of general surgery training. The more complex procedures involving these organs are limited in number in most general surgery residencies and do not afford an opportunity for vast experience. Moreover, fellowship programs in hepato-bilio-pancreatic (HPB) surgery and the development of laparoscopic techniques may have further limited the familiarity of general surgery residents with these operations. To determine the experience accrued by finishing general surgery residents, we accessed, through the Residency Review Committee of the Accreditation Council for Graduate Medical Education, the Resident Case Log System used by general surgery residents throughout their training to document operative cases. The number of operations on the gallbladder, bile ducts, pancreas, and liver was examined over the past 16 years (there were missing data for 3 years). Reference years 1995 and 2005 were compared to detect trends. Experience with laparoscopic cholecystectomy has steadily increased and averaged more than 100 cases in 2006. Experience in liver resection, distal pancreatectomy, and partial (Whipple) pancreatectomy has statistically improved from 1995 to 2005, but the numbers of cases are low, generally less than five per finishing resident. Experience in open common bile duct and choledocho-enteric anastomoses has statistically declined from 1995 to 2005, averaging less than four cases per finishing resident. The mode (most frequently performed number) for liver and pancreas resections was either 0 or 1. It is doubtful this experience in HPB surgery engenders confidence in many finishing residents. Attention should be focused on augmenting training in HPB surgery for general surgery residents perhaps through a combination of programmatic initiatives, ex vivo experiences, and minifellowships. Institutional initiatives might consist of defined HPB services with appropriate expertise, infrastructure, process, and outcome measures in which a resident-oriented, competency-based curriculum could be developed.

Medication reconciliation in a rural trauma population.

STUDY OBJECTIVE: Medication errors during hospitalization can lead to adverse drug events. Because of preoccupation by health care providers with life-threatening injuries, trauma patients may be particularly prone to medication errors. Medication reconciliation on admission can result in decreased medication errors and adverse drug events in this patient population. The purpose of this study is to determine the accuracy of medication histories obtained on trauma patients by initial health care providers compared to a medication reconciliation process by a designated clinical pharmacist after the patient's admission and secondarily to determine whether trauma-associated factors affected medication accuracy. METHODS: This was a prospective enrollment study during 13 months in which trauma patients admitted to a Level I trauma center were enrolled in a stepwise medication reconciliation process by the clinical pharmacist. The setting was a rural Level I trauma center. Patients admitted to the trauma service were studied. The intervention was medication reconciliation by a clinical pharmacist. The main outcome measure was accuracy of medication history by initial trauma health care providers compared to a medication reconciliation process by a clinical pharmacist who compared all sources, including telephone calls to pharmacies. Patients taking no medications (whether correctly identified as such or not) were not analyzed in these results. Variables examined included admission medication list accuracy, age, trauma team activation mode, Injury Severity Score, and Glasgow Coma Scale (GCS) score. RESULTS: Two hundred thirty-four patients were enrolled. Eighty-four of 234 patients (36%) had an Injury Severity Score greater than 15. Medications were reconciled within an average of 3 days of admission (range 1 to 8) by the clinical pharmacist. Overall, medications as reconciled by the clinical pharmacist were recorded correctly for 15% of patients. Admission trauma team medication lists were inaccurate in 224 of 234 cases (96%). Admitting nurses' lists were more accurate than the trauma team's (11% versus 4%; 95% confidence interval 2.5% to 11.2%). Errors were found by the clinical pharmacist in medication name, strength, route, and frequency. No patients (0/20) with admission GCS less than 13 had accurate medication lists. Seventy of 84 patients (83%) with an Injury Severity Score greater than 15 had inaccurate medication lists. Ten of 234 patients (4%) were ordered wrong medications, and 1 adverse drug event (hypoglycemia) occurred. The median duration of the reconciliation process was 2 days. Only 12% of cases were completed in 1 day, and almost 25% required 3 or more (maximum 8) days. CONCLUSION: This study showed that medication history recorded on admission was inaccurate. This patient population overall was susceptible to medication inaccuracies from multiple sources, even with duplication of medication histories by initial health care providers. Medication reconciliation for trauma patients by a clinical pharmacist may improve safety and prevent adverse drug events but did not occur quickly in this setting.

Effect of the final rule on the conduct of emergency clinical research.

The development of life-saving techniques in medical emergencies often requires enrollment of patients into clinical trials without the opportunity for informed consent. The Food and Drug Administration had designated such exemptions from informed consent for the purpose of emergency research as "the Final Rule." In the decade following the Final Rule for emergency research, little progress has been made in the study of therapies for acute, life-threatening conditions with high mortality rates. The potential for significant change in accepting research without consent begins with a level of public knowledge, trust, and credibility in the healthcare delivery system. This review seeks to address the Final Rule and its ramifications and issues that undermine the provisions of emergency research. In understanding the complexities of emergency research and its potential, there are opportunities for improvement for the scientific community to develop a greater understanding of the general public's attitudes and perceptions concerning research without consent.

Predictors of nonalcoholic steatohepatitis in patients undergoing bariatric surgery: when is liver biopsy indicated?

BACKGROUND: Nonalcoholic fatty liver disease is a frequent accompaniment of morbid obesity. A component of nonalcoholic fatty liver disease, steatosis, can, on occasion, lead to nonalcoholic steatohepatitis (NASH). Bariatric surgery has been shown to alter the course of this disease. Intraoperative liver biopsies might identify patients with NASH for more careful follow-up. We sought to determine noninvasive preoperative indicators of NASH. METHODS: The patients scheduled for bariatric surgery underwent a preoperative assessment. The study variables included age, gender, race, body mass index, diabetes mellitus, hypertension, and the results of serum liver function tests and triglyceride, cholesterol, iron, and prealbumin measurements. Univariate and multivariate analyses were performed to identify significant variables associated with NASH as determined by subsequent core liver biopsies taken during open Roux-en-Y gastric bypass. RESULTS: A total of 139 patients were entered into the study. NASH or NASH-associated fibrosis was found in 57 patients (41%). On univariate analyses, male gender (odds ratio [OR] 2.46, P = .06), diabetes mellitus (OR 2.60, P = .009), elevated serum triglyceride levels (OR 1.003, P = .02), elevated gamma glutamyl transferase (OR 1.015, P = .01), and decreased prealbumin (OR 0.94, P = .04) correlated with the presence of NASH. On multivariate analysis, only increased triglycerides (OR 1.004, P = .04) and decreased prealbumin (OR 0.88, P = .005) correlated with the presence of NASH. CONCLUSION: NASH is a frequent accompaniment of morbid obesity in patients undergoing bariatric surgery. Univariate and multivariate analyses of the clinical parameters studied could not identify strong predictors of biopsy-verified NASH. Therefore, intraoperative biopsy remains instrumental in diagnosing NASH and providing information for additional follow-up.

Referrals for surgical therapy in patients with hepatocellular carcinoma: a community experience.

The treatment of hepatocellular carcinoma (HCC) is notoriously difficult. Either because of oncogenic behavior or the frequent association of cirrhosis, successful therapy is elusive, particularly in cirrhotic patients. Surgical removal has been the only modality that has produced long-term, disease-free survival. In a large series of patients from specialty institutions, median survival in those who underwent resection of HCC lesions has ranged from 30 to 70 months. Similarly, liver transplantation has been shown to be an effective treatment when HCC is favorable (limited in size and number), producing long-term survival in greater than 70% of patients. However, less information is known about community-based treatment of HCC. Reports from referral centers may not accurately reflect the community experience. We have retrospectively reviewed patients with HCC seen in surgical referral from three teaching hospitals in a medium-size urban community from 1995 to 2004 who were not felt to be candidates for liver transplantation and who were not sent to referral centers. We sought to examine their suitability for operation and resection. The study group comprised 61 patients, whose ages ranged from 35 to 83 years old. There were 44 patients (72%) with cirrhosis (Childs A, B, and C in 27, 15, and 2 patients, respectively), 21 from hepatitic C virus (HCV) infection. Three recognized staging systems were used that incorporated the estimation of hepatic reserve and tumor burden. Seven patients (11%) were deemed nonoperable (five advanced disease by imaging, two comorbidities). Of the 54 patients who underwent surgical procedures, 32 underwent resection (28 patients) or cryoablation (4 patients). The reasons for unresectability were unrecognized multifocality (ten patients), poor risk for major hepatectomy (five patients), portal vein/hepatic vein involvement (three patients), metastatic disease (two patients), and excessive blood loss prior to hepatectomy (two patients). Eleven of 17 (65%) noncirrhotic patients and 21 of 44 (48%) cirrhotic patients were resectable or ablatable. There were ten postoperative deaths: six following resection, two following cryoablation, and two following exploratory celiotomy. All deaths were in cirrhotic patients (Childs A in four patients, B in five patients, and C in one patient), 10 of 44 patients (23%); 3 of 11 (27%) patients died following segmentectomy and 3 of 9 (33%) following major hepatectomy. Seven deaths that occurred were in patients with HCV; (P = NS). From this series, the difficulty in surgically treating cirrhotic patients in an urban practice is evident. From 39 to 73% of patients had advanced local disease. Less than half were resectable and, for cirrhotic patients, the postoperative mortality was high, even after "minor" hepatectomies. Noncirrhotic patients fared somewhat better. While HCC in community practice can be treated surgically in the majority of noncirrhotic patients, cirrhotic patients are less likely candidates, and surgical treatment is associated with significant postoperative mortality. This frequently reflected advanced disease and HCV but may be associated with access to preventative and surveillance measures. Only those with optimum hepatic reserve and small tumor burden should be considered for surgical resection.

Operative versus non-operative management in the care of patients with complicated appendicitis.

BACKGROUND: The approach to complicated appendicitis is unclear. We have sought to determine factors which may persuade surgeons to non-operative management and whether such treatment affects outcome. METHODS: All adult patients admitted over a five-year period 2009-2014 with a diagnosis of appendicitis were reviewed. Patients were grouped into uncomplicated and complicated presentations and stratified by age, gender, ethnicity, socio-economic status, and time to presentation. Mortality, morbidity, length of hospital stay (LOS), readmission, and hospital charges were used as outcome measures. RESULTS: 611 adult patients were admitted with the diagnosis of appendicitis. Of those 306 patients presented in an uncomplicated manner, and 305 patients were complicated presentations. Selection for non-operative management was significantly correlated with older age and a longer time to presentation. For outcome patients who underwent early surgery experienced a longer LOS (5.8 ± 4.4 days versus 3.4 ± 4.5 days, p < 0.0001), and more readmissions. CONCLUSION: Surgical treatment of patients presenting with complicated appendicitis is preferable to non-operative, antibiotic oriented treatment in reduction of LOS and need for readmissions.