Association of Prophylaxis and Length of Stay With Venous Thromboembolism in Abdominopelvic Surgery.

INTRODUCTION: Extended venous thromboembolism prophylaxis (eVTEp) is recommended for select patients who have undergone major abdominopelvic surgery to prevent postdischarge venous thromboembolism (pdVTE). Criteria for selection of these patients are untested for this purpose and may be ineffective. To address this gap, we investigated the effectiveness of eVTEp on pdVTE rates. METHODS: A retrospective cohort study of patients undergoing abdominopelvic surgery from January 2016 to February 2020 was performed using data from the Michigan Surgical Quality Collaborative. pdVTE was the main outcome. Our exposure variable, eVTEp, was compared dichotomously. Length of stay (LOS) was compared categorically using clinically relevant groups. Age, race, cancer occurrence, inflammatory bowel disease, surgical approach, and surgical time were covariates among other variables. Descriptive statistics, propensity score matching, and multivariable logistic regression were performed to compare pdVTE rates. RESULTS: A total of 45,637 patients underwent abdominopelvic surgery. Of which, 3063 (6.71%) were prescribed eVTEp. Two hundred eighty-five (0.62%) had pdVTE. Of the 285, 59 (21%) patients received eVTEp, while 226 (79%) patients did not. After propensity score matching, multivariable logistic regression analysis showed pdVTE was associated with eVTEp and LOS of 5 d or more (P < 0.001). eVTEp was not associated with LOS. Further analysis showed increased risk of pdVTE with increasing LOS independent of prescription of eVTEp based on known risk factors. CONCLUSIONS: pdVTE was associated with increasing LOS but not with other VTE risk factors after propensity score matching. Current guidelines for eVTEp do not include LOS. Our findings suggest that LOS >5 d should be added to the criteria for eVTEp.

Histologic progression of acne inversa/hidradenitis suppurativa: Implications for future investigations and therapeutic intervention.

Since first recognized in 1839, the pathogenesis of acne inversa (AI) has undergone repeated revisions. Although there is agreement that AI involves occlusion of hair follicles with subsequent inflammation and the formation of tracts, the histologic progression of this disease still requires refinement. The objective of this study was to examine the histologic progression of AI based on the examination of a large cohort of punch biopsies and excisional samples that were examined first by hematoxylin and eosin staining. The most informative of these samples were step-sectioned and stained by immunohistochemistry for epithelial and inflammatory markers. Based on this examination, the following observations were made: 1) AI arises from the epithelium of the infundibulum of terminal and vellus hairs; 2) These form cysts and epithelial tendrils that extend into soft tissue; 3) Immunohistochemical staining demonstrates the epithelium of AI is disordered with infundibular and isthmic differentiation and de novo expression of stem cell markers; 4) The inflammatory response in AI is heterogeneous and largely due to cyst rupture. The conclusions of this investigation were that AI is an epithelial-driven disease caused by infiltrative, cyst forming tendrils and most of the inflammation is due to cyst rupture and release of cornified debris and bacteria. Cyst rupture often occurs below the depths of punch biopsy samples indicating their use for analysis may give an incomplete picture of the disease. Finally, our data suggest that unless therapies inhibit tendril development, it is unlikely they will cause prolonged treatment-induced remission in AI.

35-Year Experience with Surgical Treatment of Hidradenitis Suppurativa.

BACKGROUND: Hidradenitis suppurativa is a painful and disfiguring chronic inflammatory condition affecting both men and women. Medical treatments, such as antibiotics and immunosuppressive agents, are often ineffective. Over time, patients can suffer from recurrent abscesses, chronic purulent drainage, scarring, and contractures that can only be corrected by surgical excision. There is no agreement, however, on the best way for the surgeon to manage this condition. The purpose of this review is to describe the results of surgical treatment of this condition in a large cohort of patients managed by local excision of hidradenitis, healing by secondary intention and reoperation as needed. STUDY DESIGN: A retrospective review was conducted of all patients operated on by the author for hidradenitis over a 35-year period. Specific data abstracted included patient age, weight, admission, length of stay, wound size, type of wound care, number of post-op visits, time to heal, and recurrence. Most wounds healed by secondary intention and were managed using simple tap water-moistened plain gauze dressings changed three times a day. RESULTS: From 1979 through 2014, 122 patients (56 men and 66 women), median age 38, underwent 245 operations for hidradenitis suppurativa. Patients underwent from 1 to 10 procedures; 61 patients (50%) underwent two or more procedures; and 26 (21%) underwent three or more. Wound sizes at operation ranged from quite small to over 1500 cm2. Men were older (42 vs 34 years, p < 0.001) and had larger median wound size (98 vs 55 cm2, p < 0.001). A total of 197 wounds healed by secondary intention: 83 of these (median size 159 cm2) were left completely open at the time of surgery; 117 (median size 100 cm2) were partially closed. A total of 30 wounds (median size 38 cm2) were closed primarily; 15 (median size 196 cm2) were closed by skin graft. Patients undergoing 139 procedures were admitted to the hospital for the initial wound care. Their median combined total wound size was 160 cm2; length of stay was 5.5 days; and median time to heal was 60 days. In total, 106 procedures were ambulatory; median wound size was 30 cm2; and median time to heal was 40 days. Recurrent or new disease was common, with some patients requiring multiple procedures over many years to maintain control of symptoms. Although wound healing can take up to several months, patients quickly learned how to care for themselves and were usually pain-free after the first two or three weeks. CONCLUSIONS: Surgical treatment of hidradenitis suppurativa by wide local excision with healing by secondary intention using tap water-moistened plain gauze dressings changed 2-3 times per day is a simple, practical approach that has good results. Recurrence of disease is common and should not be thought of as a failure of surgical treatment, but rather as a feature of the disease that must be anticipated and managed.

Safety and long-term outcomes of percutaneous endoscopic gastrostomy in patients with head and neck cancer.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is used for nutritional support during treatment in patients with head and neck cancer, but long-term nutritional outcomes have not been reported in detail. The purpose of this study was to determine short- and long-term outcomes and success in meeting nutritional goals in patients with head and neck cancer who had PEGs placed over an 18-year period. METHODS: Medical records of all patients who had PEG procedures performed by one of the authors (REB) from 1997 through 2010 were reviewed. Demographic data, patient weights, timing of procedure in relation to cancer treatment, complications, and long-term outcomes were recorded. RESULTS: Five hundred and sixty-five patients with head and neck cancer underwent PEG. Mean age was 59.6 ± 13.6 years; 71% were men. Mean follow-up was 33 ± 38 months. 99% of PEGs were used for nutritional support. Average weight loss prior to PEG was 23 ± 17 lbs (range 0-133 lbs). Average weight loss between PEG and completion of treatment was 2.3 lbs; 44% of patients gained weight or remained stable after PEG. There were no PEG-related deaths. Complications included cellulitis in 27 (4%), pain in 14 (2.5%); leakage in 11 (2%), self-limited gastric bleeding in one patient. PEGs were used an average of 8.1 months. No PEG site tumor implants were observed. Among 366 patients treated with intention to cure, 45% were alive an average of 68 months later. CONCLUSIONS: PEG is both safe and efficacious in arresting weight loss and maintaining nutrition in patients undergoing surgery and/or chemoradiotherapy for head and neck cancer. PEG can be recommended for patients in whom dysphagia and weight loss is anticipated or in whom weight loss occurs as a result of their treatment; 20% of patients will need the PEG for a year or more.

Test-specific funnel plots for healthcare provider profiling leveraging individual- and summary-level information.

In addition to applications in meta-analysis, funnel plots have emerged as an effective graphical tool for visualizing the detection of health care providers with unusual performance. Although there already exist a variety of approaches to producing funnel plots in the literature of provider profiling, limited attention has been paid to elucidating the critical relationship between funnel plots and hypothesis testing. Within the framework of generalized linear models, here we establish methodological guidelines for creating funnel plots specific to the statistical tests of interest. Moreover, we show that the test-specific funnel plots can be created merely leveraging summary statistics instead of individual-level information. This appealing feature inhibits the leak of protected health information and reduces the cost of inter-institutional data transmission. Two data examples, one for surgical patients from Michigan hospitals and the other for Medicare-certified dialysis facilities, demonstrate the applicability to different types of providers and outcomes with either individual- or summary-level information.

Vulvar varicosities mimicking a hernia: case report.

OBJECTIVE: Vulvar varicosities are not uncommon in pregnancy, but there are only a few published reports of symptomatic vulvar varicosities in nonpregnant women. CASE: We report 2 cases of women presenting with symptomatic vulvar masses that were more prominent after exercise or with elevated intra-abdominal pressure. Symptoms included an intermittent vulvar bulge or mass and moderate pain when the masses were present. Imaging studies did not reveal the nature of these masses. On surgical exploration, they were found to be large vulvar varicosities. CONCLUSIONS: Vulvar masses can be caused by hernias, tumors, cysts, or other unusual entities. Differentiating among these etiologies can be a diagnostic challenge. Although most often a positional vulvar mass is a sign of hernia, it is important to be aware that masses that come and go can be caused by other entities, including large varicose veins.

D-Day to December 1944: The odyssey of the third auxiliary surgical group in World War II.

ABSTRACT: As a Major in the US Army Medical Corps, Darrell A. Campbell, MD, led Team 13 of the Third Auxiliary Surgical Group in Europe in World War II. The team began work on June 7, 1944, in a clearing station tent near the beach at Normandy. Subsequently, over the next 7 months, it was assigned to mobile hospitals in 15 different locations in France, Belgium, Luxembourg, and Germany. Major Campbell kept the log books used to record all of the operations done by his team during this time and brought them home where three were discovered more than 70 years later. These log books contain descriptions of more than 500 consecutive operations done by Team 13. They provide a unique insight into the activities of the surgeons who worked to save lives on the front lines of battle in the European Theater of Operations between June and December 1944 and form the basis for this historical perspective.This is an article on the history of surgery.

An international perspective on ultrasound training and use for thyroid and parathyroid disease.

BACKGROUND: Use of ultrasound (USN) by endocrine surgeons has dramatically increased. Presently, optimal training and certification requirements have not been standardized at any level (resident/fellow/attending). We sought to define the types of USN training endocrine surgeons receive and how USN is employed in practice. We hypothesized that in more recent years fellowship-trained endocrine surgeons were more likely to receive formal training in the use of USN during their endocrine surgery fellowship. METHODS: A survey link was sent via email to a large group of endocrine surgeons around the world asking about the settings in which they received USN training, the type of instruction received, current use of USN, and other various questions. chi(2) analysis was performed and P < 0.05 was considered significant. RESULTS: One hundred twenty-one surveys were collected from respondents in 27 countries. Median time from completion of residency to the present was 17 years (range = 2-49). Fifty-nine percent of both fellowship- and nonfellowship-trained endocrine surgeons currently use USN in their practice. Of those currently performing USN, 38% reported no USN training of any kind (47% international vs. 23% United States). USN experience among international and U.S. residents was not different (P = 0.27). Fifty-nine percent of respondents reported completing an endocrine surgery fellowship; of those, 85% reported no formal USN training. Forty-one percent reported not being comfortable performing USN at the completion of their endocrine surgery fellowships, requiring the presence of someone else to assist with the exam. CONCLUSIONS: USN training among endocrine surgeons varies widely around the world. Despite an increase in the number of formal endocrine surgery fellowships offered, it does not appear that the number with formal USN training and certification has increased. Formal USN certification is achieved in only a minority of cases among practicing endocrine surgeons. It is currently unknown whether there is a difference in competency between endocrine surgeons with formal versus informal USN training.

Contribution of plasma cells and B cells to hidradenitis suppurativa pathogenesis.

Hidradenitis suppurativa (HS) is a debilitating chronic inflammatory skin disease characterized by chronic abscess formation and development of multiple draining sinus tracts in the groin, axillae, and perineum. Using proteomic and transcriptomic approaches, we characterized the inflammatory responses in HS in depth, revealing immune responses centered on IFN-γ, IL-36, and TNF, with lesser contribution from IL-17A. We further identified B cells and plasma cells, with associated increases in immunoglobulin production and complement activation, as pivotal players in HS pathogenesis, with Bruton's tyrosine kinase (BTK) and spleen tyrosine kinase (SYK) pathway activation as a central signal transduction network in HS. These data provide preclinical evidence to accelerate the path toward clinical trials targeting BTK and SYK signaling in moderate-to-severe HS.

Treatment of pilonidal disease by minimal surgical excision under local anesthesia with healing by secondary intention: Results in over 500 patients.

BACKGROUND: The surgical treatment of pilonidal disease is highly variable. The present study examines the long-term results in over 500 patients treated by minimal but complete surgical excision under local anesthesia with healing by secondary intention using moist dressings. METHODS: Records of all patients I treated for pilonidal disease from 1978 to 2015 with at least 1 year of follow-up were reviewed. Symptoms, prior surgical treatments, extent of disease, number of clinic visits, length of time until wound healed, compliance with wound care instructions, and length of follow-up were recorded. RESULTS: Records were found for 570 patients; mean follow-up was 4.7 years. Two hundred forty-eight patients (44%) had a prior abscess requiring drainage; 80 had from 1 to 6 prior operations. Ninety-two percent of operations were performed under local anesthesia. Men had more extensive disease than women (5.2 vs 3.5 cm, P < .001) and took longer to heal (median 46 days in women, 51 days in men, P < .001). Eighteen patients (3.2%) had persistent or recurrent disease requiring reoperation, most often because of poor compliance with wound care instructions, and later healed. CONCLUSION: The majority of patients with pilonidal disease can be managed by simple, minimal excision of affected tissue under local anesthesia with healing by secondary intention. With careful attention to wound care, morbidity is minimal and the recurrence or failure rate is less than 5%.

The impact of primary hyperparathyroidism on the oral cavity.

CONTEXT: Primary hyperparathyroidism (HPT) is a systemic disease causing bone loss. Periodontal disease is a local inflammatory disease characterized by alveolar bone loss. The older literature records that HPT is associated with loss of radicular lamina dura and brown tumors of the bone, but contemporary studies are lacking. OBJECTIVE: The objective of the study was to determine the effects of HPT on oral bony structures and periodontal disease in a contemporary population. DESIGN: This was a cross-sectional, case-controlled study. SETTING: The study was conducted at the clinics of endocrine surgery and hospital dentistry. PATIENTS AND OTHER PARTICIPANTS: Fifty-nine patients, 39 with HPT and 20 thyroid controls, were included in the study. MAIN OUTCOME MEASURES: Periodontal clinical measures and dental radiographic analyses were used in this study. RESULTS: HPT patients were more likely to have tori and reductions in radicular lamina dura on dental radiographs. Widening of the periodontal ligament space surrounding teeth correlated with serum PTH levels. Panoramic radiographs demonstrated reduced cortical bone thickness at the angle of the mandible in HPT patients but no evidence of brown tumors or other overt pathologies. CONCLUSIONS: Changes in the oral cavity observed in patients with HPT suggested both decreased cortical density and increased likelihood of oral tori. The contemporary oral manifestations of primary HPT are different from those previously reported, and health care providers should be aware of newer, more subtle findings that may be present when treating patients with HPT.

Interpretation of intraoperative parathyroid hormone monitoring in patients with baseline parathyroid hormone levels of <100 pg/mL.

BACKGROUND: Common guidelines for intraoperative parathyroid hormone (IOPTH) interpretation are based on clearly elevated baseline parathyroid hormone (PTH) values. We hypothesize that patients with low-baseline levels (<100 pg/mL) have a higher incidence of multigland disease (MGD) and display differences in PTH kinetics compared with patients with high-baseline levels. METHODS: We retrospectively reviewed the cases of 1151 patients with primary hyperparathyroidism who underwent parathyroidectomy with IOPTH monitoring. Of these, 141 patients had low-baseline values. Multiple comparisons were made between the low-baseline and high-baseline groups. RESULTS: Twenty-six percent of the low-baseline patients had MGD versus 15% of the high-baseline patients (P = .002). The PTH kinetics differed between groups after gland excision at both 5 and 10 minutes. Adherence solely to the "50% rule" during minimally invasive parathyroidectomy potentially would have missed 25% of patients with MGD in the low-baseline group versus 10% in the high-baseline group; 5.7% of the low-baseline patients had persistent or recurrent hypercalcemia versus 2.9% of the high-baseline patients. CONCLUSION: MGD is significantly more prevalent among low-baseline patients, and PTH kinetics are somewhat different between groups. The current guidelines that are used for IOPTH monitoring may not be ideal for use in this low-baseline group and will likely need to be revised after further study of this group of patients.

Colovaginal Fistulas: Presentation, Evaluation, and Management.

OBJECTIVE: The objective of this study was to review a single institution's experience with colovaginal fistulas to provide guidance toward identification and management of this problem. METHODS: Patients with colovaginal fistulas treated by 2 senior surgeons between January 1, 1990, and June 31, 2011, were identified. A retrospective chart review was then performed to determine presenting characteristics and history, evaluation for the fistulas, and treatment outcomes. RESULTS: Nineteen patients were identified. The mean age was 63.5 years and median parity of 2. 37% complained of flatus per vagina, 89% reported stool per vagina, and 68% noted vaginal discharge. Ninety-five percent had previously undergone hysterectomy. The fistulas were identified at the left vaginal apex in 90% of the subjects. Self-reported history and/or operative findings suggested diverticulitis as the most common etiology (79% of the subjects). All subjects underwent sigmoid resection with primary anastomosis, with complete symptom resolution in 84%. CONCLUSIONS: Patients with colovaginal fistulas commonly present for primary evaluation by gynecologists. A triad of symptoms and history should trigger a high index of suspicion for colovaginal fistulas: (1) complaints of stool or flatus per vagina or foul-smelling vaginitis resistant to treatment, (2) previous hysterectomy, and (3) history of diverticulitis. The fistulas can often be visualized on speculum examination at the left vaginal apex. Rolling the patient from left to right lateral decubitus positions during a contrast enema study can improve its sensitivity. Repair of colovaginal fistulas via rectosigmoid resection and primary reanastomosis is safe and effective. We recommend multidisciplinary management involving colorectal surgery and gynecology.

Is preoperative iodine 123 meta-iodobenzylguanidine scintigraphy routinely necessary before initial adrenalectomy for pheochromocytoma?

BACKGROUND: Iodine 123 meta-iodobenzylguanidine (MIBG) scintigraphy has been used in patients with clinical suspicion of pheochromocytoma to confirm the nature of an adrenal or extraadrenal mass or to identify occult disease. Additionally, it may be used to identify unsuspected bilaterality or metastases in the setting of a known unilateral adrenal mass before operation. We sought to determine the role of (123)I MIBG scintigraphy in this apparently routine preoperative setting. Our hypothesis was that (123)I MIBG would provide additional preoperative information that could modify operative intervention. METHODS: All patients undergoing (123)I MIBG scintigraphy at our institution between 1992 and 2002 were identified. MIBG results, operative procedures and findings, and pathologic findings were retrospectively reviewed and compared. RESULTS: The (123)I MIBG scintigraphy was performed in a total of 315 patients. Of these, 48 were patients with an initial biochemical diagnosis of pheochromocytoma and a unilateral adrenal mass. 47 of the 48 (98%) primary scans were positive for a single focus of activity concordant with anatomic imaging data from computed tomography or magnetic resonance imaging and operative findings. The (123)I MIBG did not reveal unsuspected metastatic or bilateral disease in any patient. CONCLUSION: In this large series of patients undergoing (123)I MIBG scintigraphy, the test served only to confirm diagnostic impressions and corroborate anatomic imaging. The (123)I MIBG did not alter the operative management of any patient with a solitary adrenal lesion in the clinical context of biochemically-proven catecholamine excess.

The influence of sample site on intraoperative PTH monitoring during parathyroidectomy.

BACKGROUND: Intraoperative parathyroid hormone (IOPTH) monitoring is common during parathyroidectomy. We hypothesized that sample site (peripheral vs central vein) may impact IOPTH interpretation. METHODS: Two hundred and one patients underwent curative parathyroidectomy for single-gland disease. IOPTH was drawn peripherally (PV) in 114 patients and centrally (CV, jugular vein) in 87 patients. Decrease from baseline IOPTH and the presence of a normal value at 10 and 15 minutes were determined. The slope of IOPTH decay was calculated. These data were compared between sample sites. RESULTS: Median baseline IOPTH was 268 pg/mL (CV) and 191 pg/mL (PV, P = .003). The mean IOPTH decay slopes were -0.75 (PV) and -0.76 (CV, P = NS), and the mean percent IOPTH decrease at 10 minutes was 79% PV and 80% CV (P = NS). At 10 minutes, a > or =50% drop from baseline was seen in 94% (CV) versus 97% (PV) of patients ( P = NS), resulting in a median IOPTH of 40 pg/mL (CV) versus 34 pg/mL (PV, P = .09). By 15 minutes, the central IOPTH had decreased by > or =50% of baseline in 98% of patients ( P = NS when compared to the 10-minute PV site). CONCLUSIONS: IOPTH kinetics are largely the same for PV and CV sample sites, but baseline values are higher with central sampling. Consequently, CV IOPTH levels are generally higher at 10 minutes, but this discrepancy resolves by 15 minutes. The surgeon utilizing CV samples may need to extend the sampling period.

Comparison of spinal vs general anesthesia via laryngeal mask airway in inguinal hernia repair.

HYPOTHESIS: The use of laryngeal mask airway and propofol in inguinal hernia repair results in shorter operative and recovery room times. DESIGN: Randomized control trial. SETTING: University hospital. PATIENTS: From May 2000 to March 2002, a convenience sample of 79 patients was invited to participate; 34 entered the study. Fifteen patients were randomized to subarachnoid block, and 18 patients were randomized to laryngeal mask airway. No patients withdrew from the study because of adverse effects. All study subjects were followed up for 6 months. INTERVENTION: General anesthesia via laryngeal mask airway or lidocaine subarachnoid block anesthesia for inguinal hernia repair. MAIN OUTCOME MEASURES: Operative and recovery room times; surgeon evaluation of the adequacy of the anesthetic technique; 36-Item Short-Form Health Survey scores before and after operation. RESULTS: Total time from entry into the operating room to discharge home was slightly longer in the subarachnoid block group (285 vs 262 minutes; 95% confidence interval, 251-317 minutes) but this difference was not statistically or clinically significant. Patient satisfaction was high with both techniques; patient-reported outcomes were the same. Surgeons rated muscle relaxation and exposure better with the subarachnoid block. CONCLUSIONS: We found no differences between short-acting spinal anesthesia and general anesthesia via laryngeal mask airway with intravenous propofol in efficiency or in early or late outcomes after elective inguinal hernia repair. Surgeon and patient preferences appear to be the most important reasons for selecting an anesthetic technique for individual patients undergoing inguinal hernia repair.