Tree Stand-Related Injuries in Nonadmitted and Admitted Patients at a Level 2 Trauma Center in Michigan: 2015-2019.

INTRODUCTION: Tree stand-related injuries (TSRI) are more common than firearm-related injuries in hunters. Most previous studies on the topic used trauma databases that only include admitted patients. This study characterizes injury patterns found in nonadmitted and admitted TSRI patients presenting to a level 2 Michigan trauma center. TSRI prevention interventions are also discussed. METHODS: Cases were obtained through a retrospective chart review of the Henry Ford Allegiance Health trauma registry and EPSi cost-accounting database from 2015 to 2019. Keywords searched included fall, hunter, tree, tree stand, treestand, ICD 9 diagnosis (E884.9_Other accidental fall from one level to another), and ICD 10 diagnosis (W14.XXXA_Fall from tree, initial encounter). We analyzed age, sex, body mass index, injury severity score, disposition, alcohol use, injuries sustained, reported height of fall, and narrative of fall. RESULTS: Thirty-three patients were identified. Patient age was 45±13 y (mean±SD). All patients were male. Injury severity score for nonadmitted patients was 2±1 vs 13±11 in admitted patients. Thirty-three percent of cases were nonadmitted; 67% were admitted. The most common injuries sustained were spinal (33%) and lower extremity fractures (15%). The average yearly TSRI case rate was 5.73 per 10,000 hunters in the study area. CONCLUSIONS: Our study found that spinal and lower extremity fractures were the most common injuries sustained. One-third of our patients were nonadmitted and therefore not included in the Henry Ford Allegiance Health trauma registry. Some nonadmitted patients had significant injuries requiring specialist consultation, orthopedic braces, or outpatient surgery.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

A prospective comparison of totally minimally invasive versus open Ivor Lewis esophagectomy.

The majority of esophagectomies in Western parts of the world are performed by a transthoracic approach reflecting the prevalence of adenocarcinoma of the lower esophagus or esophagogastric junction. Minimally invasive esophagectomy (MIE) has been reported in a variety of formats, but there are no series that directly compare totally minimally invasive thoracolaparoscopic 2 stage esophagectomy (MIE-2) with open Ivor Lewis (IVL). A prospective single-center cohort study of patients undergoing elective MIE-2 or IVL between January 2005 and November 2010 was performed. Short-term clinicopathologic outcomes were recorded using validated systems. One hundred and six patients (median age 66, range 36-85, 88 M : 18 F) underwent two-stage esophagectomy (53 MIE-2 and 53 IVL). Patient demographics (age, sex, body mass index, American Society of Anesthesiologists grade, tumor characteristics, neoadjuvant chemotherapy, and TNM stage) were comparable between the two groups. Outcomes for MIE-2 and IVL were comparable for anastomotic leak rates (5 [9%] vs. 2 [4%], P= 0.241), resection margin clearance (R0) (43 [81%] vs. 38 [72%], P= 0.253), median lymph node yield (19 vs. 18, P= 0.584), and median length of stay (12 [range 7-91] vs. 12 [range 7-101] days), respectively. Blood loss was significantly less for MIE-2 compared with IVL (median 300 [range 0-1250] mL vs. 400 [range 0-3000] mL, respectively, P= 0.021). MIE-2 in this series of selected patients supports its efficacy, when performed by an experienced minimally invasive surgical team. A well-designed multicenter trial addressing clinical effectiveness is now required.

A two-consultant approach is a safe and efficient strategy to adopt during the learning curve for laparoscopic Roux-en-Y gastric bypass: our results in the first 100 procedures.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) can be technically challenging. It is imperative that patient morbidity and mortality are minimized while teams are on the learning curve for this procedure. METHODS: This retrospective study evaluated the peri-operative risk of LRYGBP utilizing a two-consultant surgeon approach in a newly established bariatric service. 100 consecutive patients undergoing LRYGBP were included. Two consultants participated in each procedure. RESULTS: Median operative duration was 113 minutes (range 80-240) and fell with increasing experience [127 minutes (range 90-240) in cases 1-50 and 105 minutes (range 80-210) in cases 51-100; P=0.009]. Multivariate analysis found operation time correlated only with number of procedures performed (P<0.001). There were no conversions to laparotomy. Intra-operatively, 2 patients had hand-assisted completion of the jejuno-jejunostomy, and 2 underwent laparoscopic revision of the reconstruction. Postoperative complications were observed in 8 patients on the operative admission. Median stay was 4 days (range 3-7). 4 patients required readmission. There was no mortality. Percentage of excess BMI loss was 47%, 53% and 70% at 3, 6 and 12 months respectively. CONCLUSION: A learning curve for LRYGBP is evidenced in this series by reduction in operative time with increasing experience. Complication rates in line with large published series can be achieved by adopting a two-surgeon approach, which we propose as a safe method to adopt in the development of new bariatric services.

Tumour dosimetry in human liver following hepatic yttrium-90 microsphere therapy.

Radiation dose distributions arising from intrahepatic arterial infusion of 90Y microspheres have been investigated. Tissue samples from normal liver, the tumour periphery and tumour centre were taken from a patient following infusion of 3 GBq of 32 microm diameter resin microspheres labelled with 90Y as treatment for an 80 mm diameter metastatic liver tumour. The measured microsphere distributions in three dimensions were used to calculate radiation dose patterns. Although microspheres concentrated in the tumour periphery, heterogeneous doses were delivered to all tissues. Within the tumour periphery average doses ranged from 200 Gy to 600 Gy with minimum doses between 70 Gy and 190 Gy. The average and minimum doses for the tumour centre sample were 6.8 Gy and 3.7 Gy respectively. In the normal liver sample the average dose was 8.9 Gy with a minimum dose of 5 Gy. Less than 1% of the normal liver tissue volume received more than 30 Gy, the level above which complications have resulted for whole liver exposure using external beam radiotherapy. These calculations suggest that preferential deposition of microspheres in the well-vascularized periphery of large tumours will lead to a high proportion of the tumour volume receiving a therapeutic dose, with most of the normal liver tissue being spared substantial damage.

Evaluating pterygium severity: a survey of corneal specialists.

PURPOSE: Accurate and reliable evaluation techniques are essential for clinical and epidemiologic studies. This survey of corneal specialists was designed to lay a foundation for the further development of methods for evaluating and staging pterygium. METHODS: In a self-administered, mailed questionnaire, 213 corneal specialists rated the importance of nine symptoms, nine signs, and nine clinical tests for the severity of primary pterygium. Severity was defined as the present need for surgical intervention. RESULTS: The most important factors for determining primary pterygium severity were the extent of encroachment onto the cornea, decreased visual acuity, restricted ocular motility, and increased rate of growth. Many patient symptoms were rated as moderately to highly important. The questionnaire was shown to have good response reliability by test-retest comparisons. Cronbach's alpha was 0.89, which indicates very good internal consistency reliability. CONCLUSION: The survey identifies the priorities of experts in determining the severity of pterygium. More precise and clearly defined evaluation methods will enhance future clinical and epidemiologic studies of pterygium. The ranked list of pterygium signs, symptoms, and tests can serve as a guide for developing pterygium evaluation methods in the future. There is a need for a method that accurately and precisely quantifies the distance of pterygium encroachment onto the cornea and the pterygium progression rate. Furthermore, there is a need for an assessment of patient symptoms.

Analysis of the distribution of intra-arterial microspheres in human liver following hepatic yttrium-90 microsphere therapy.

The microscopic distribution of microspheres in human liver following hepatic infusion of 32 microm diameter resin microspheres labelled with 90Y as treatment for an 80 millimetre diameter liver cancer has been investigated. Microspheres were found to deposit inhomogeneously in tissues, preferentially lodging in a region approximately 6 mm wide around the periphery of the tumour. A relative concentration of microspheres of 50 to 70 times that of normal hepatic parenchyma and 65 to 94 times that in the tumour centre was measured in this region. The deposition of spheres in the tumour periphery was not uniform, and cluster analysis showed that the spheres could be classified into clusters. The number of microspheres in a cluster was skewed towards low numbers and cluster sizes varied from 20 to 1500 microm. The observed deposition patterns indicate that the vascular tumour periphery will receive much greater radiation doses from radioactive microspheres than both normal tissue and the avascular tumour centre.

Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures.

OBJECTIVE: To establish a simple, reproducible, and safe technique of laparoscopic common bile duct exploration (CBDE) with high clearance rates and low morbidity and mortality rates. SUMMARY BACKGROUND DATA: For most general surgeons, laparoscopic CBDE appears an unduly complex and demanding procedure. Since the introduction of laparoscopic cholecystectomy, many surgeons use endoscopic cholangiography (ERC) and endoscopic sphincterotomy as their only option in treating bile duct stones. ERC is more specific if used after surgery, but it carries an appreciable morbidity rate and has the disadvantage of requiring a second procedure to deal with bile duct stones. To this end, various methods of laparoscopic CBDE have been developed. METHODS: Between August 1991 and February 1997, 300 consecutive unselected patients underwent laparoscopic CBDE. RESULTS: Of 300 laparoscopic CBDE procedures, 173 (58%) were managed using a transcystic approach and 127 (42%) with choledochotomy. Successful laparoscopic stone clearance was achieved in 271 (90%). Of the 29 (10%) patients not cleared laparoscopically, 10 had an elective postsurgical ERC, 12 were converted to an open procedure early in the series, and 7 had unexpected retained stones. There was one death (mortality rate 0.3%) and major morbidity occurred in 22 patients (7%). The last 100 procedures were performed from July 1995 to February 1997, and stone clearance was unsuccessful in only two patients. CONCLUSIONS: Laparoscopic transcystic basket extraction of common duct stones under fluoroscopic guidance is a relatively quick, successful, and safe technique. Choledochotomy, when required, is associated with a higher morbidity rate, particularly with T-tube insertion, and the authors advocate primary bile duct closure with or without insertion of a biliary stent as a more satisfactory technique for both surgeon and patient. Most patients with gallbladder and common duct calculi should expect a curative one-stage laparoscopic procedure without the need for external biliary drainage or ERC.

Laparoscopic underrunning of bleeding duodenal ulceration: a minimalist approach to therapy.

Surgical management of bleeding duodenal ulcer has traditionally included a procedure to reduce gastric acid production to enable ulcer healing and reduce the likelihood of rebleeding. The availability of intravenous proton pump inhibitors in the peri-operative period may promote rapid ulcer healing and as a component of anti-Helicobacter eradication therapy greatly reduces the incidence of ulcer recurrence. Using this approach, six patients with actively bleeding duodenal ulcer underwent laparoscopic duodenotomy and attempted suturing of the bleeding site. One patient required conversion to open surgery and subsequently re-bled at 60 h, necessitating a partial (Billroth II) gastrectomy. In the remaining five patients suture control of bleeding and luminal closure were completed laparoscopically without complications. Laparoscopic repair of acutely bleeding duodenal ulcers is technically feasible and had a low complication rate in this small series.

Laparoscopic management of acute small bowel obstruction.

BACKGROUND: Laparoscopic management of acute small bowel obstruction is hypothetically attractive but little is known of its clinical potential. METHODS: A retrospective study was undertaken of patients with acute small bowel obstruction requiring surgery, managed by a laparoscopic unit (LU; n = 69) and a general unit (GU; n = 70). RESULTS: Laparoscopy was performed in 55 patients (80 per cent) in the LU compared with ten (14 per cent) in the GU. Laparoscopic surgery completed treatment in 31 patients (45 per cent) in the LU and assisted in a further 15 (22 per cent). Patients treated laparoscopically were discharged earlier than those treated by laparotomy (median 3 (range 1-15) versus median 8 (range 1-46) days). Patients treated laparoscopically had a higher chance of early unplanned reoperation than those treated by laparotomy (five of 35 versus four of 88) (P < 0.05). CONCLUSION: Laparoscopy can be performed in a high percentage of patients requiring surgery for acute small bowel obstruction. Hospital stay was reduced but the risk of early unplanned reoperation was increased in patients managed laparoscopically.

Vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes. Results of a multicentered randomized clinical trial. The Vitrectomy for Treatment of Macular Hole Study Group.

OBJECTIVE: To prospectively assess the risks and benefits of vitrectomy surgery for eyes with stage 3 or 4 macular holes. DESIGN: A multicentered, controlled, randomized clinical trial. SETTING: Community- and university-based ophthalmology clinics. PATIENTS: One hundred twenty patients (129 eyes) with stage 3 or 4 macular holes. INTERVENTIONS: Standardized macular hole surgery vs observation alone. MAIN OUTCOME MEASURES: Four measures of best-corrected visual function, standardized photographic evaluation of the extent of hole closure, evaluation of lens opacification, and determination of adverse events. Outcomes were determined at 6 months after randomization. RESULTS: Compared with observation alone, a significant benefit due to surgery was found in the rate of hole closure (4% vs 69%, P < .001). After adjusting for baseline visual acuity, hole duration, and maximum hole diameter, a significant benefit due to surgery was found in visual acuity for the Bailey-Lovie Word Reading (P = .02) and the Potential Acuity Meter (P < .01) tests; a marginally significant benefit due to surgery was found in visual acuity for the Early Treatment Diabetic Retinopathy Study chart (P = .05). Although the proportion of eyes achieving a change in visual acuity of 2 or more lines on the Early Treatment Diabetic Retinopathy Study chart was significantly greater for the surgery group vs the observed group (11 [19%] of 59 eyes vs 3 [5%] of 58 eyes, adjusted P = .05), 20 (34%) of 59 eyes randomized to surgery had a loss in visual acuity of 1 or more lines. Compared with the observation group, eyes randomized to surgery had higher nuclear sclerosis scores (2.4 vs 1.3, P < .001). Fourteen adverse events were noted in the surgery group; none were noted in the observed group. CONCLUSIONS: Some visual benefit of vitrectomy surgery for macular holes exists, despite a notable incidence of adverse events. The large variability in visual acuity outcome in the surgical group may be because of complications or progressive cataract. A study of the long-term outcome after macular hole surgery is needed.

Prospective randomized trial of vitrectomy or observation for stage 2 macular holes. Vitrectomy for Macular Hole Study Group.

PURPOSE: To determine the risks and benefits of vitrectomy surgery in eyes with stage 2 macular holes. METHODS: A multicentered, controlled, randomized clinical trial was performed with participation of 16 community and university-based ophthalmology clinics. Thirty-six eyes with stage 2 macular holes and 12 months of follow-up were studied. Pars plana vitrectomy with separation of the posterior hyaloid membrane and intraocular injection of perfluoropropane (C3F8) was followed by postoperative face-down positioning for two weeks. This protocol was compared with observation alone. Outcome variables included anatomic closure of the macular hole, macular hole size, and four standardized measures of vision. RESULTS: At 12 months, 15 (71%) of 21 eyes randomly assigned to observation progressed to stages 3 or 4, compared with three (20%) of 15 eyes randomly assigned to surgery (P < .006). Compared with eyes randomly assigned to observation, eyes randomly assigned to surgery had significantly smaller hole diameters (P < .01) and significantly better visual acuity outcomes, as measured by the Word Reading (P = .02) and Potential Acuity Meter (P = .002) charts. No significant differences were found for the Early Treatment Diabetic Retinopathy Study chart and Contrast Sensitivity test. CONCLUSION: Compared with observation alone, surgical intervention in stage 2 macular holes resulted in a significantly lower incidence of hole enlargement and appeared to be associated with better outcome in some measures of visual acuity.

Antimicrobial prophylaxis in 'clean' surgery: hernia repair.

Antimicrobial prophylaxis is not traditionally employed for patients undergoing 'clean' surgery. The true rates of septic complications are grossly under reported for this group of patients, with up to 72% of all complications occurring, undetected by the surgical team, after discharge from hospital. The implied costs of these infections, coupled with the costs to both the patient and the community services, suggest that antimicrobial prophylaxis should be seriously considered for many types of 'clean' surgery. This can now be made both more straightforward and cost-effective by employing the oral route of administration.

The role of motor evoked potentials in the management of hysterical paraplegia: case report.

The role of motor evoked potentials in the management of a case of presumed hysterical paraplegia precipitated by spinal injury in a man with a previous history of surgery for scoliosis is presented. Motor evoked potentials were elicited with magnetic stimulation 12 days after injury and were within normal limits. The presence of normal motor electrophysiology and observation by the patient of involuntary movement of the lower limbs during stimulation greatly facilitated the patient's management. These findings are discussed with reference to current diagnostic investigations in the presence of a suspected diagnosis of hysterical paraplegia.

Community surveillance of complications after hernia surgery.

OBJECTIVE: To assess the effect of a programme of postoperative community surveillance on the rate of detection of wound complications after operation for inguinal hernia. DESIGN: Prospective audit of wound complications including complications recorded in case notes and those discovered by community surveillance. SETTING: Academic surgical unit of three consultant surgeons. PATIENTS: 510 patients undergoing elective inguinal hernia repair between June 1985 and August 1989. RESULTS: The wound infection rate recorded in the hospital notes was 3% compared with 9% when additional information was obtained from community surveillance. Wound complications were detected in 143 (28%) patients by community surveillance compared with a complication rate of 7% in the case records for the same patients. CONCLUSIONS: Wound complications are common after clean surgery in patients discharged home early. Complication rates are a reflection not only of the standards of surgical practice but also the rigour with which they are sought. Before national comparative audit data are published the method of collection must be standardised. For short stay surgery this should include meaningful community surveillance.

Surgery offers the best palliation for carcinoma of the pancreas.

This debate discusses the palliative management of pancreatic cancer. The arguments in favour of surgical palliation are that this approach allows all symptoms to be treated or prevented, the diagnosis can be confirmed histologically and a final assessment of resectability can be made. The arguments against the use of surgery are that survival is short and that effective alternative therapies are available: endoscopic intubation, percutaneous coeliac plexus block and pancreatic enzyme supplements. The most appropriate policy, however, is to tailor the management plan to suit the individual patient.

A clinicopathological review of spinal ependymomas in Northern Ireland.

Of eighty-three tumours of ependymal origin diagnosed in the twenty years 1969-1988 in Northern Ireland, fifteen were located within the spine. Two were in children, 13 in young adults with a mean age of 33 years. 70% presented with back pain and 60% had weakness of the lower limbs. Survival was found to correlate well with histological grading (WHO classification). The mean time of survival for tumours graded 1/2 was six years; there were three long-term survivors of 13, 17 and 18 years; 90% of the patients survived 2.5 years.