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Background Cholecystectomy in patients with hematologic malignancies remains poorly understood. Methods We retrospectively evaluated patients with hematologic malignancies who underwent cholecystectomy at a single institution. Results Of 313 patients who presented for evaluation of abdominal pain, 64 underwent cholecystectomy for acute cholecystitis (34.4%), gangrenous cholecystitis (21.9%), chronic cholecystitis (23.4%), and cholelithiasis (20%). Most had a history of hematopoietic cell transplantation (62.5%) and/or immunosuppressive medication within 30 days of consultation (82.8%). Ultrasound had a 39% false-negative rate for acute nongangrenous cholecystitis. Operative time was 92 ± 39 min, 7 were performed open, 10 had intraoperative transfusions, and 4 had grade 3+ complications. Intraoperative transfusion was associated with increased postoperative length of stay (p = 0.03). Open procedure, operative time, estimated blood loss, intraoperative transfusion, and complications were not associated with timing of surgery. Conclusions Patients with hematologic malignancies can safely undergo cholecystectomy. Length of postoperative stay for inpatients is associated with intraoperative blood transfusion.

Robotic surgery bedside assistants play an important role in robotic procedures by performing intra-corporeal tasks while accommodating the physical presence of the robot. We hypothesized that an augmented reality headset enabling 3D intra-corporeal vision while facing the surgical field could decrease time and improve accuracy of robotic bedside tasks. Bedside assistants (one physician assistant, one medical student, three surgical trainees, and two attending surgeons) performed validated tasks within a mock abdominal cavity with a surgical robot docked. Tasks were performed with a bedside monitor providing 2D or 3D vision, or an optical see-through head-mounted augmented reality device with 2D or 3D vision. The effect of augmented reality device resolution on performance was also evaluated. For the simplest task of touching a straw, performance was generally high, regardless of mode of visualization. With more complex tasks, including stapling and pulling a ring along a path, 3D augmented reality decreased time and number of errors per task. 3D augmented reality allowed the physician assistant to perform at the level of an attending surgeon using 3D augmented reality (p = 0.08). All participants had improved times for the ring path task with better resolution (lower resolution 23 ± 11 s vs higher resolution 14 ± 4 s, p = 0.002). 3D augmented reality vision with high resolution decreased time and improved accuracy of more complex tasks, enabling a less experienced robotic surgical bedside assistant to function similar to attending surgeons. These data warrant further study with additional complex tasks and bedside assistants at various levels of training.

We previously reported that professional forms of address in speaker introductions were inconsistently used at the Society of Surgical Oncology (SSO) 2018 and 2019 annual meetings, suggesting unconscious bias in speaker introductions. We sought to better understand how speakers would like to be introduced, and if guidelines could improve consistency in speaker introductions. SSO 2021 abstract submitters received a survey regarding demographics and preferred form of address at the meeting. Respectful discourse guidelines were developed and distributed to meeting moderators. Speaker introductions were reviewed for the 2021 SSO annual meeting and were compared with the 2018 and 2019 meetings. The survey response rate was 183/347 (53%) abstract submitters, most of whom (143/183, 78%) indicated preference for a professional form of address (Doctor/Professor) during speaker introductions, which was significantly greater than those who were introduced with a professional form of address during the 2018 and 2019 meetings (351/499, 70%; Chi-square = 4.08, p = 0.043). There was no difference in speaker introduction preference based on gender or race/ethnic identification. Respectful discourse guidelines were developed and distributed to meeting moderators. During the 2021 SSO annual meeting, professional forms of address were used for 104 (84%) speakers, significantly greater than during the 2018 and 2019 meetings (Chi-square = 9.23, p = 0.002). More survey respondents preferred speaker introductions with a professional form of address than were used in prior meetings. This preference was similar across all demographic groups evaluated. Professional addresses during speaker introductions increased significantly after the distribution of guidelines encouraging consistency to decrease unconscious bias and promote an inclusive environment.

For patients with stage III melanoma with occult lymph node metastasis, the use of adjuvant therapy is increasing, and completion lymph node dissection (CLND) is decreasing. We sought to evaluate the use of modern adjuvant therapy and outcomes for patients with stage III melanoma who did not undergo CLND. Patients with a positive SLNB from 2015 to 2020 who did not undergo CLND were evaluated retrospectively. Nodal recurrence, recurrence-free survival (RFS), distant metastasis-free survival (DMFS), and melanoma-specific survival were evaluated. Among 90 patients, 56 (62%) received adjuvant therapy and 34 (38%) underwent observation alone. Patients who received adjuvant therapy were younger (mean age: 53 vs. 65, p

Background The advantages of robotic liver surgery are strongest for minor resections, where incision size drives recovery time, but cost remains a concern. We hypothesized that patients who underwent robotic minor liver resections would have superior peri-operative outcomes resulting in decreased cost. Methods We queried the medical record and cost data for patients who underwent open or robotic minor (1–2 segment) liver resection from 1/2016–8/2019. Financial data were normalized to Medicare reimbursements. Results There were 87 patients who underwent minor liver resections (robotic n = 46, open n = 41). Specimen size (173 ± 203 vs 257 ± 481 cm3), surgical duration (233 ± 87 vs 227 ± 83 min), estimated blood loss (187 ± 236 vs 194 ± 165 mL), and margin status (89% vs 93% R0) were similar for robotic and open resections respectively, yet complications (3/46, 7% vs 10/41, 24%, p = 0.02) and length of stay (2.2 ± 2.2 vs 6.2 ± 2.9, p Conclusion Patients undergoing robotic minor hepatectomy had superior peri-operative outcomes resulting in lower total cost of care when compared to open minor hepatectomy. Financial considerations should not adversely influence selection of a robotic approach for minor hepatectomy.

There is a paucity of prospective data related to surgeon ergonomics, which affects career longevity. Robotic surgical systems may mitigate pain and workload. We hypothesized that ergonomic outcomes would vary based on surgeon height and gender, and the relative benefit of robotic surgery would vary based on these demographics. Surgeons received questionnaires to fill out immediately before and after surgery to enable calculation of pain scores and task load. Surgeons who were ≤ 66 inches tall were considered “short”. Univariable and multivariable regression analyses were performed where appropriate using Stata-MP version 14.2 (StataCorp LLC, College Station, TX). There were 124 questionnaires given to 20 surgeons; 97 (78%) were returned, and 12 (12%) laparoscopic operations were excluded, leaving 85 (69%) questionnaires for further analysis: 33 (38%) from short surgeons, and 24 (28%) from women, for 30 (35%) robotic and 55 (65%) open operations. There were 44/85 (52%) surgeons who reported worse pain after surgery. Overall pain scores (1.1 ± 2.6 vs 1.5 ± 2.6, p = 0.70) were similar for robotic and open operations. In multivariable analysis, greater surgeon pain scores were significantly associated with short surgeons (p

Robotic surgery is now within the standard of care for many operations, including hepatectomy. Robotic liver surgery has advantages over laparoscopic and open surgical techniques, but these must be weighed against certain limitations when selecting an approach. Advantages and limitations of robotic liver surgery are discussed here based on a literature survey. Advantages include improved surgeon ergonomics, better access to posterior and superior liver segments, excellent visualization, and ease of using indocyanine green. There may also be a shorter learning curve for use, and there are possibilities for technological assistance with surgery in the future. Limitations are related to those known for minimally invasive surgery in general, but also include time for docking and cost. Considerations are reviewed in detail to facilitate decision making when considering a robotic approach for liver surgery. The robotic platform is not appropriate for all liver operations at this time. Benefits of robotic surgery are most clearly realized when approaching lesions in the posterior and superior segments, and when a large incision would be required to remove a small amount of liver parenchyma were the operation to be performed in an open fashion.

Intraoperative hyperglycemia is associated with infectious complications in general surgery patients. This study aimed to determine if the use of lactated Ringer’s (LR) carrier solution during hyperthermic intraperitoneal chemotherapy (HIPEC) would lower the incidence of intraoperative hyperglycemia and improve postoperative outcomes when compared with a standard 1.5% dextrose peritoneal dialysate carrier solution. This is a retrospective cohort study of 134 patients who underwent HIPEC at the University of Colorado. Perioperative glucose levels and outcomes were compared between patients who were perfused with 1.5% dextrose peritoneal dialysate carrier solution (n = 68) versus LR carrier solution (n = 66). The study population consisted of patients undergoing HIPEC for appendiceal (50%), colorectal (34%), mesothelioma (8%), and ovarian cancer (5%). Intraoperative severe hyperglycemia (glucose ≥ 180 mg/dL) was significantly more common among patients perfused with a dextrose-containing carrier solution versus those perfused with LR (88% vs. 21%; p

Background Minimally invasive surgery (MIS) is preferred for distal pancreatectomy but is not always attempted due to the risk of conversion to open. We hypothesized that the total cost for MIS converted to open procedures would be comparable to those that started open. Methods A prospectively collected institutional registry (2011-2017) was reviewed for demographic, clinical, and perioperative cost data for patients undergoing distal pancreatectomy. Results There were 80 patients who underwent distal pancreatectomy: 41 open, 39 MIS (11 laparoscopic and 28 robotic). Conversion to open occurred in 14 of 39 (36%, 3 laparoscopic and 11 robotic). Length of stay was shorter for the MIS completed (6 days; range, 3-8), and MIS converted to open (7 days; range, 4-10) groups, compared with open (10 days; range, 5-36; P = .003). Laparoscopic cases were the least expensive (P = .02). Robotic converted to open procedures had the highest operating room cost. However, the total cost for robotic converted to open cohort was similar to the open cohort due to cost savings associated with a shorter length of stay. Conclusions Despite the higher intraoperative costs of robotic surgery, there is no significant overall financial penalty for conversion to open. Financial considerations should not play a role in selecting a robotic or open approach.

OBJECTIVE We hypothesized that OR airborne PM was different in quantity and mutagenic potential than office air and cigarette smoke. SUMMARY OF BACKGROUND DATA Exposure to surgical smoke has been equated to cigarette smoking and thought to be hazardous to health care workers despite limited data. METHODS PM was measured during 15 operations in ORs with 24.8 ± 2.0 air changes/h, and in controls (cigarettes, office air with 1.9-2.9 air changes/h). Mutagenic potential was assessed by gamma Histone 2A family member X staining of DNA damage in small airway epithelial cells co-cultured with PM. RESULTS Average PM concentration during surgery was 0.002 ± 0.002 mg/m3 with maximum values at 1.08 ± 1.30 mg/m3. Greater PM correlated with more diathermy (ρ = 0.69, P = 0.006). Values were most often near zero, resulting in OR average values similar to office air (0.002 ± 0.001 mg/m3) (P = 0.32). Cigarette smoke average PM concentration was significantly higher, 4.8 ± 5.6 mg/m3 (P < 0.001). PM collected from 14 days of OR air caused DNA damage to 1.6% ± 2.7% of cultured cells, significantly less than that from office air (27.7% ± 11.7%, P = 0.02), and cigarette smoke (61.3% ± 14.3%, P < 0.001). CONCLUSIONS The air we breathe during surgery has negligible quantities of PM and mutagenic potential, likely due to low frequency of diathermy use coupled with high airflow. This suggests that exposure to surgical smoke is associated with minimal occupational risk.

Computed tomography (CT) image-guided procedures including biopsy, drug delivery, and ablation are gaining increasing application in medicine. Robotic technology holds the promise for allowing surgeons, and other proceduralists, access to such CT guided procedures by potentially shortening training, improving accuracy, decreasing needle passes, and reducing radiation exposure. We evaluated surgeon learning and proficiency for image-guided needle placement with an FDA-cleared robotic arm. Five out of six surgeons had no prior CT guided procedural experience, while one had prior experience with freehand CT guided needle placement. All surgeons underwent a 60-minute training with the MAXIO robot (Perfint Healthcare, Redmond, WA). The robot was used to place needles into three different pre-specified targets on a spine model. Performance time, procedural errors, and needle placement accuracy were recorded. All participants successfully placed needles into the targets using the robotic arm. The average time for needle placement was 3:44 ± 1:43 minutes. Time for needle placement decreased with subsequent attempts, with average third placement taking 2:29 ± 1:51 minutes less than the first attempt. The average vector distance from the target was 2.3 ± 1.2 mm. One error resulted in the need for reimaging by CT scan. No errant needle placement occurred. Surgeons (attending fellows and residents) without previous experience and minimal training could successfully place percutaneous needles under CT guidance quickly, accurately, and reproducibly using a robotic arm. This suggests that robotic technology may be used to facilitate surgeon adoption of CT image-guided needle-based procedures in the future.

Importance Cannabis is increasingly being used for medicinal purposes but remains outside Western medical practice. Data on perioperative use and outcomes are scarce. Few surgeons receive training regarding legal endorsement, reported medicinal benefits, and potential risks, making it difficult to advise patients. Guidelines and additional research are needed. Observations It is legal to recommend cannabis, which can be obtained in states with medical cannabis programs. There are many methods of consumption, oral being the safest. Activity is primarily through Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) via cannabinoid receptors, which may be potentiated when taken together in the plant or plant extract. The known effects of cannabis on inflammation and malignancy are largely limited to laboratory experiments. However, there are higher-quality data to support adjunctive use of cannabis for relief of pain, nausea, and insomnia, which may be useful postoperatively and could potentially decrease reliance on opiates and benzodiazepines. There are prospective trials in surgical patients, but no reported data regarding surgical complications or other surgical outcomes. Currently, cannabis is regulated differently than other controlled substances, and there are issues with purity/homogeneity, making it difficult for surgeons to accept or significantly explore its medical benefits. Conclusions and Relevance Recommendations are made for surgeons advising patients who use cannabis based on the limited existing data. While cannabis likely has some therapeutic benefits, it must be treated as other medical controlled substances to truly elucidate its role in surgical patient care.

Robotic surgery has rapidly evolved. It is particularly attractive as an alternative minimally invasive approach in liver surgery because of improvements in visualization and articulated instruments. Limitations include increased operative times and lack of tactile feedback, but these have not been shown in studies. Considerations unique to robotic surgery, including safety protocols, must be put in place and be reviewed at the beginning of every procedure to ensure safety in the event of an emergent conversion. Despite the lack of early adoption by many hepatobiliary surgeons, robotic liver surgery continues to evolve and find its place within hepatobiliary surgery.

Resection of colorectal liver metastases is considered a safe and effective treatment. As technical hurdles related to the extent of resection and its relationship to perioperative morbidity and mortality are surmounted, determining which candidates for surgery will derive the most benefit becomes more challenging. Clinical scoring systems for colorectal liver metastases were initially devised to help determine the tipping point between survival advantage and risk of surgery for individual patients. The goal was to identify a combination of factors that predicted which patients could achieve long-term survival meriting the invasiveness of the procedure, while also identifying those best suited for additional studies, to aid in clinical decision-making for adjuvant therapy and in consideration for clinical trials. They would further provide prognostic information for the patient.

Sentinel lymph node biopsy (SLNB) for head and neck melanoma is challenging due to unpredictable drainage. We sought to determine the frequency of drainage to multiple lymphatic basins and asked if this was associated with prognosis in a large, single-center cohort.We queried patients diagnosed with head and neck melanomas who had a SLNB performed from January 1998 to April 2016. Demographic and clinical characteristics were compared using Student's t test, Pearson chi-square analysis, log-rank test, Wilcoxon-Mann-Whitney test, and Kaplan-Meier curves.We identified 269 patients with head and neck melanoma that had SLNBs performed in the following locations: 223 neck, 92 parotid/preauricular, 29 occipital/posterior auricular, 1 axilla. There were 68 (25%) patients who had drainage to multiple basins. These patients were similar to those with single basin drainage in age, gender distribution, Breslow depth, and percent with a positive SLNB (all p0.05). Fewer patients with drainage to multiple basins had a completion lymph node dissection (CLND, p = 0.03). A trend toward increased 3-year locoregional recurrence was seen for patients with drainage to multiple basins in univariate analysis (27% vs. 18%, p = 0.10) but was lost in multivariate analysis (p = 0.49), possibly because of higher recurrence rates in patients with positive nodes but no CLND (p = 0.02). No difference was detected for distant recurrence or overall survival based on SLN drainage.Head and neck melanoma SLNB drainage to multiple basins is common. Drainage to multiple basins does not seem to be associated with increased sentinel lymph node positivity, locoregional recurrence, distant recurrence, or survival.

We hypothesized that general surgeons are more likely to use a robotic surgical platform at hospitals where more urologic and gynecologic robotic operations are performed, suggesting that hospital-related factors are important for choice of usage of minimally invasive platforms.We queried the National Inpatient Sample from 2010 to 2014 for patients who underwent stomach, gallbladder, pancreas, spleen, colon and rectum, or hernia (general surgery), prostate or kidney (urologic surgery), and ovarian or uterine surgery (gynecologic surgery). Hospitals were grouped into quartiles according to percent volume of robotic urologic or gynecologic operations. Multivariable logistic regression modeling determined independent variables associated with robotics.Survey-weighted results represented 482,227 open, 240,360 laparoscopic, and 42,177 robotic general surgical operations at 3,933 hospitals. Robotics use increased with each year studied and was more likely to be performed on younger men with private insurance. The odds of a general surgery patient receiving a robotic operation increased with urologic and gynecologic use at the hospital. Patients at top quartile hospitals for robotic urologic surgery had 1.34 times greater odds of receiving robotic general surgery operations (confidence interval 1.15-1.57, P.001) and 1.53 times greater odds (confidence interval 1.32-1.79, P.001) at top quartile robotic gynecologic hospitals. These findings were independent of study year, surgical site, insurance type, and hospital type and persisted when only comparing laparoscopic to robotic procedures.Use of robotics in general surgery is independently associated with use in urologic and gynecologic surgery at a hospital, suggesting that institutional factors are important drivers of use when considering laparoscopy versus robotics in general surgery.

e18758 Background: There are now numerous effective adjuvant immunotherapy options for surgically resected stage III melanoma including novel checkpoint inhibitors and targeted therapies. Current guidelines recommend that the decision to treat stage III melanoma with adjuvant immunotherapy should be individualized and based upon disease burden, patient goals and anticipated therapy tolerance. We sought to assess the contribution of patient, tumor and facility factors on the implementation of immunotherapy in patients with surgically resected stage III melanoma. Methods: Using the National Cancer Database (NCDB), patients from 2012-2017 that underwent excision and were found to have a positive sentinel node were identified. A multivariable mixed effects logistic regression model with a random intercept for site was used to determine the effect of patient, tumor, and facility variables on the probability of immunotherapy. Reference Effect Measures (REM) were used to estimate the variation in immunotherapy use due to unmeasured facility factors (contextual effects) after adjusting for measured patient, tumor, and facility variables. Results: From 2012 to 2017, the percent of patients with stage III melanoma treated with adjuvant immunotherapy increased from 23.7% to 38.5% (p < 0.05). Overall, younger patients and patients with private insurance were more likely to receive immunotherapy. Tumor factors associated with increased use of adjuvant immunotherapy included increasing depth, mitotic rate ³1, ulceration, lymphovascular invasion (LVI), and undergoing a completion lymph node dissection (CLND). Additionally, treatment at a facility with a surgical volume

Humans are able to compensate for significant blood loss with little change in traditional vital signs. We hypothesized that an algorithm, which recognizes compensatory changes in photoplethysmogram (PPG) waveforms, could detect active bleeding and ongoing volume loss in injured patients.Injured adults were prospectively enrolled at a level I trauma center. PPG data collection was conducted using a custom-made pulse oximeter. Waveform data were post-processed by an algorithm to calculate the compensatory reserve index (CRI), measured on a scale of 1 to 0, with 1 indicating fully compensated and 0 indicating no reserve, or decompensation. CRI was compared to clinical findings.Fifty patients were enrolled in the study; 3 had incomplete data, 3 had indeterminate bleeding, 12 were actively bleeding, and 32 were not bleeding. The mean initial CRI of bleeding patients was significantly lower compared with the non-bleeding patients (CRI 0.17, 95% CI = 0.13-0.22 vs. CRI 0.56, 95% CI = 0.49-0.62, P 0.001). Using a cut-off of 0.21 had a sensitivity of 0.97 and specificity of 0.83 for identifying bleeding patients. CRI had a higher sensitivity than heart rate (75%), systolic blood pressure (63%), shock index (27%), base deficit (29%), lactate (80%), hemoglobin (50%), and hematocrit (50%). During ongoing bleeding, CRI decreased following fluid resuscitation, and conversely increased for patients who were not bleeding.A novel computational algorithm that recognizes subtle changes in PPG waveforms can quickly and noninvasively discern which patients are actively bleeding and continuing to bleed with high sensitivity and specificity in acutely injured patients.

Robotic surgery is offered at most major medical institutions. The extent of its use within general surgical oncology, however, is poorly understood. We hypothesized that robotic surgery adoption in surgical oncology is increasing annually, that is occurring in all surgical sites, and all regions of the US. We identified patients with site-specific malignancies treated with surgical resection from the National Inpatient Sample 2010–2014 databases. Operations were considered robotic if any ICD-9-CM robotic procedure code was used. We identified 147,259 patients representing the following sites: esophageal (3%), stomach (5%), small bowel (5%), pancreas (7%), liver (5%), and colorectal (75%). Most operations were open (71%), followed by laparoscopic (26%), and robotic (3%). In 2010, only 1.1% of operations were robotic; over the 5-year study period, there was a 5.0-fold increase in robotic surgery, compared to 1.1-fold increase in laparoscopy and 1.2-fold decrease in open surgery (

To assess postbiopsy pigmentation (PBP) as a prognostic feature in patients with cutaneous head and neck (HN) melanoma.Retrospective review of patients undergoing sentinel lymph node biopsy (SLNB) for HN melanoma (1998-2018). PBP was defined as visible remaining pigment at the scar or biopsy site that was documented on physical exam by both a medical oncologist and a surgeon at initial consultation. Variables associated with disease-free survival (DFS) and overall survival (OS) were analyzed using multivariable Cox proportional hazards models.Among 300 patients, 34.3% (n = 103) had PBP and 44.7% (n = 134) had microscopic residual disease on final pathology after wide local excision. Prognostic factors associated with DFS included advanced age, tumor depth, ulceration, PBP, and positive SLNB (p 0.05). Patients with PBP fared worse than their counterparts without PBP in 5-year DFS [44.1% (31.1-56.3%) vs. 73.0% (64.1-80.0%); p 0.001] and 5-year OS [65.0% (50.0-76.6%) vs. 83.6% (75.7-89.2%); p = 0.005]. After multivariable adjustment, PBP remained associated with shorter DFS [hazard ratio (HR) 1.72, 95% confidence interval (CI) 1.01-2.93; p = 0.047], but was not prognostic of OS.In patients with HN melanoma, PBP is associated with significantly shorter DFS. Patients with PBP may warrant greater consideration for SLNB and closer postoperative surveillance.

Colorectal cancer commonly metastasizes. The liver is the most frequent site of metastases and dominates the length of survival for this disease. As surgical and systemic therapies have become accepted and now are proven to be potentially curative, other sites of metastases have become more clinically relevant in terms of clinical symptoms and influence on survival. Treatment of extrahepatic metastases by surgical and ablative procedures is increasingly accepted and is proving to be effective at palliating symptoms, as well as life prolonging. In this review, we will first summarize key issues with metastatic colorectal cancer to the liver and available treatments. We will then discuss surgical and ablative treatments of other sites of disease including lung, lymph nodes, peritoneum, bone, and brain. Best available evidence for treatment strategies will be presented as well as potential new directions.

Background Helicopter emergency medical services (HEMS) are a common mode of transportation for pediatric trauma patients. We hypothesized that HEMS improve outcomes for traumatically injured children compared to ground emergency medical services (GEMS). Methods We queried trauma registries of two level 1 pediatric trauma centers for children 0–17 years, treated from 2003 to 2013, transported by HEMS or GEMS, with known transport starting location and outcome. A geocoding service estimated travel distance and time. Multivariate regression analyses were performed to adjust for injury severity variables and travel distance/time. Results We identified 14,405 traumatically injured children; 3870 (26.9%) transported by HEMS and 10,535 (73.1%) transported by GEMS. Transport type was not significantly associated with survival, ICU length of stay, or discharge disposition. Transport by GEMS was associated with a 68.6%–53.1% decrease in hospital length of stay, depending on adjustment for distance/time. Results were similar for children with severe injuries, and with propensity score matched cohorts. Of note, 862/3850 (22.3%) of HEMS transports had an ISS Conclusions HEMS do not independently improve outcomes for traumatically injured children, and 22.3% of children transported by HEMS are not significantly injured. These factors should be considered when requesting HEMS for transport of traumatically injured children.

On November 28, 1942, a fire broke out at The Cocoanut Grove Nightclub, in Boston, Massachusetts. The fire claimed the lives of hundreds, and injured 170 patients who were treated at either Boston City Hospital or the Massachusetts General Hospital. With extraordinary leadership and scientific focus, this tragedy led to many important advances in burn management, including improvements in burn wound care, the first descriptions of inhalation injury, formulas to guide fluid resuscitation, and the initial studies of antimicrobial therapy with burns. This overview describes the treatment of the Cocoanut Gove victims, and how it transformed the management of burns forever.

The fluid resuscitation needs of children with small area burns are difficult to predict. The authors hypothesized that a novel computational algorithm called the compensatory reserve index (CRI), calculated from the photoplethysmogram waveform, would correlate with percent total body surface area (%TBSA) and fluid administration in children presenting with ≤20% TBSA burns. The authors recorded photoplethysmogram waveforms from burn-injured children that were later processed by the CRI algorithm. A CRI of 1 represents supine normovolemia; a CRI of 0 represents the point at which a subject is predicted to experience hemodynamic decompensation. CRI values from the first 10 minutes of monitoring were compared to clinical data. Waveform data were available for 27 children with small to moderate sized burns (4-20 %TBSA). The average age was 6.3 ± 1.1 years, the average %TBSA was 10.4 ± 0.8%, and the average CRI was 0.36 ± 0.03. CRI inversely correlated with the %TBSA (P.001). Twenty children were transferred with an average reported %TBSA of 16.5 ± 1.4%, which was significantly higher than the actual %TBSA (P.001). CRI correlated better with actual %TBSA compared to reported %TBSA (P = .02). CRI correlated with the amount of fluid resuscitation given at the time of CRI measurement (P = .02) and was inversely related to total fluids given per 24 hours for children with adequate urine output (0.5 ml/kg/hr) (P.001). The CRI is decreased in children with small to moderate size burns, and correlates with %TBSA and fluid administration. This suggests that the CRI may be useful for fluid resuscitation guidance, warranting further study.

Humans are able to compensate for low-volume blood loss with minimal change in traditional vital signs. We hypothesized that a novel algorithm, which analyzes photoplethysmogram (PPG) wave forms to continuously estimate compensatory reserve would provide greater sensitivity and specificity to detect low-volume blood loss compared with traditional vital signs. The compensatory reserve index (CRI) is a measure of the reserve remaining to compensate for reduced central blood volume, where a CRI of 1 represents supine normovolemia and 0 represents the circulating blood volume at which hemodynamic decompensation occurs; values between 1 and 0 indicate the proportion of reserve remaining.Subjects underwent voluntary donation of 1 U (approximately 450 mL) of blood. Demographic and continuous noninvasive vital sign wave form data were collected, including PPG, heart rate, systolic blood pressure, cardiac output, and stroke volume. PPG wave forms were later processed by the algorithm to estimate CRI values.Data were collected from 244 healthy subjects (79 males and 165 females), with a mean (SD) age of 40.1 (14.2) years and mean (SD) body mass index of 25.6 (4.7). After blood donation, CRI significantly decreased in 92% (α = 0.05; 95% confidence interval [CI], 88-95%) of the subjects. With the use of a threshold decrease in CRI of 0.05 or greater for the detection of 1 U of blood loss, the receiver operating characteristic area under the curve was 0.90, with a sensitivity of 0.84 and specificity of 0.86. In comparison, systolic blood pressure (52%; 95% CI, 45-59%), heart rate (65%; 95% CI, 58-72%), cardiac output (47%; 95% CI, 40-54%), and stroke volume (74%; 95% CI, 67-80%) changed in fewer subjects, had significantly lower receiver operating characteristic area under the curve values, and significantly lower specificities for detecting the same volume of blood loss.Consistent with our hypothesis, CRI detected low-volume blood loss with significantly greater specificity than other traditional physiologic measures. These findings warrant further evaluation of the CRI algorithm in actual trauma settings.Diagnostic study, level II.

article i nfo Purpose: Children with diabetes mellitus (DM) who develop acute appendicitis can present a diagnostic and clinical challenge. No studies have examined this population since the advent of multiple dose insulin therapy, computed tomography, and laparoscopic surgery. We sought to characterize these children to identify their differences and how to best care for them. Methods: We retrospectively examined the medical records of children with a preexisting diagnosis of DM treated for acute appendicitis. Values are presented as the mean ± the standard error of the mean, and Student's t-test was used for statistical comparison. Results: We identified18diabeticchildrentreatedfor acute appendicitis, making this thelargest seriesofits kind. These children had similar presentations compared to non-diabetics, with the exception of often presenting without fever (83.3% with an initial temperature b38 C). All children developed significant postoperative hyperglycemia (average high 382 ± 18 mg/dL), and most had glycemic control for ≤50% of the hospitalization (14/18, 77.8%), but they otherwise had typical postoperative courses. Conclusions: Diabetic children with appendicitis are often afebrile at presentation and have serum glucose levels that are difficult to control. Collaboration with pediatric endocrinologists is needed to appropriately manage these children during their hospitalization.

Hyperthermic intraperitoneal chemotherapy (HIPEC) administration can be associated with hyperglycemia during perfusion. Little is known about this effect, and no previous studies have examined patient characteristics associated with perfusion-related hyperglycemia. We retrospectively identified consecutive patients at a single institution treated with HIPEC from 8/2003 to 10/2016 who had intraoperative blood glucose measured. Hypertonic 1.5% dextrose-containing peritoneal dialysate was used as carrier solution in all patients. Comparisons were made using parametric [Student’s t test, analysis of variance (ANOVA)], and nonparametric tests (χ 2, Kruskal–Wallis) where appropriate. There were 85 patients identified, with average age of 53 ± 12 years, 69 (81%) with appendiceal or colorectal peritoneal cancer. Most patients were perfused with mitomycin C (69%) or oxaliplatin (24%). Intraoperative hyperglycemia (> 180 mg/dL) affected the majority of patients (86%), with values up to 651 mg/dL. Insulin was required for treatment in 66% of patients. Peak hyperglycemia occurred within an hour of perfusion in 91%, and resolved by postoperative day one in 91% of patients. Glucose > 309 mg/dL (highest quartile) was associated with longer operating time (p = 0.03) and with use of oxaliplatin compared with mitomycin C (p = 0.01). No association was found with other comorbidities, peritoneal carcinomatosis index score, or postoperative outcomes. Most patients experience hyperglycemia during HIPEC. This is not clearly associated with patient factors, and may be due to use of dextrose-containing carrier solution. Since perioperative hyperglycemia has potential negative impact, use of dextrose-containing carrier solution should be questioned and is worth investigating further.

Purpose The best method for diagnosing pediatric nonnephroblastoma solid intraabdominal tumors is unknown. We hypothesized that core needle biopsy (CNB) is noninferior to open wedge biopsy (OWB) for pathologic diagnosis. Methods We prospectively enrolled children aged 1day to 17years with radiographic evidence of nonnephroblastoma solid intraabdominal tumors scheduled for OWB from 5/2013 to 12/2015 at a single institution. Four 16-gauge CNBs were obtained, followed by OWB. Two pathologists independently reviewed all specimens to determine adequacy for diagnosis. Results Fourteen patients enrolled, 57% male, with an average age of 4years (range 7days to 16years). Both pathologists agreed OWB was completely sufficient for diagnosis in 13 patients (93%), compared to 4 patients for CNB (29%: Burkitt lymphoma, adrenocortical tumor, inflammatory myofibroblastic tumor, p=0.001, δ=−0.64±0.27, 95% CI). In 6 patients (43%), CNB was incompletely diagnostic according to at least one pathologist (neuroblastoma, hepatoblastoma). In 4 patients (29%), both pathologists determined that CNB was nondiagnostic (ganglioneuroblastoma, teratoma, hepatoblastoma, and recurrent neuroblastoma). Conclusions In a prospective clinical study, CNB is inferior to OWB for the pathologic diagnosis of pediatric nonnephroblastoma solid intraabdominal tumors. These data suggest that OWB should generally be performed in these patients. Level of evidence Study of Diagnostic Test, Level I.

Within the field of local–regional hepatic therapies, the area of thermal ablation plays an important role. First conceptualized in the 1840s, thermal ablation greatly expanded after the advent of cross-sectional imaging. These techniques are generally used for patients with unresectable and borderline resectable disease, which may be due to the size, number, or location of the liver tumors, or for patients judged inoperable due to the patient’s poor health. These methods have thus become an integral part of the treatment armamentarium for liver-directed therapy. All techniques presented in this chapter can be used for either primary or metastatic hepatic malignancies, and can also be used in combination with other therapies to maximize effectiveness. Thermal ablation methods are divided into hyper- and hypothermic techniques, depending on the temperature delivered. They are further divided based on the method used for developing a temperature differential. Hyperthermic techniques include radiofrequency ablation (RFA), microwave ablation (MWA), interstitial laser photocoagulation (ILP), and high-intensity focused ultrasound (HIFU), whereas cryoablation is the sole technique that uses hypothermia. Below is a description of each of these ablation methods and how they ablate tumor, along with a review of the technical and clinical considerations that must be made when deciding to employ one of these modalities.

The optimal treatment for patients with locally advanced gastric adenocarcinoma is multimodal. Surgery is the cornerstone of therapeutic strategies with curative intent. The addition of chemotherapy or chemoradiation decreases rate of recurrence and prolongs survival. Guidelines differ between countries and there is no universal standard of care. Modern studies of patients with locally advanced gastric cancer showed that adjuvant chemotherapy improves survival over surgery alone in Asia. These studies could not be replicated in Europe. Peri-operative chemotherapy strategies, conversely, have been effective in Europe for improving overall and disease free survival. Adjuvant chemoradiation has also demonstrated improved survival when compared to surgery alone, but studies comparing chemotherapy with chemoradiation have not shown significant difference. Trials are ongoing to examine the role of chemoradiation in a neoadjuvant fashion. A D2 extent of lymphadenectomy improves cancer related survival for those who do not undergo distal pancreatectomy/splenectomy. Survival is also associated not only with the extent but also the number of lymph nodes examined. There are ongoing trials related to immunotherapy and targeted therapies, which may also impact or change the treatment paradigm for locally advanced gastric cancer.

A child's risk of developing cancer from radiation exposure associated with computed tomography (CT) imaging is estimated to be as high as 1/500. Chest CT (CCT), often as part of a "pan-scan," is increasingly performed after blunt trauma in children. We hypothesized that routine CCT for the initial evaluation of blunt injured children does not add clinically useful information beyond chest radiograph (CXR) and rarely changes management.Pediatric (15 y) trauma team evaluations over 6 y at an academic Level I trauma center were reviewed. Demographic data, injuries, imaging, and management were identified for all patients undergoing CT. Effective radiation dose in milliSieverts (mSv) was calculated using age-adjusted scales.Fifty-seven of 174 children (33%) undergoing CT imaging had a CCT; 55 (97%) of these had a CXR. Pathology was identified in significantly fewer CXRs compared with CCTs (51% versus 83%, P0.001). All 7/57 (12%) emergent or urgent chest interventions were based on information from CXR. In 53 children (93%), the CCT was ordered as part of a pan-scan, resulting in a radiation dose of 37.69 ± 7.80 mSv from initial CT scans. Radiation dose was significantly greater from CCT than from CXR (8.7 ± 1.1 mSv versus 0.017 ± 0.002 mSv, P0.001).Clinically useful information found on CCT had good correlation to information obtained from CXR and did not change patient management, however, did add significantly to the radiation exposure of initial imaging. We recommend selective use of CCT, particularly in the presence of an abnormal mediastinal silhouette on CXR after a significant deceleration injury.

Many centers use botulinum toxin for chemical pyloroplasty in minimally invasive esophagectomies as prophylaxis against delayed gastric emptying. No previous studies have compared botulinum toxin injection with no pyloric intervention for patients treated with a combined laparoscopic and thoracoscopic approach. The authors hypothesized that chemical pyloroplasty does not improve outcomes for these patients.The study investigated patients undergoing minimally invasive esophagectomies from September 2009 to June 2015. Delayed gastric emptying was defined as inability to tolerate a soft diet by postoperative day 10, as corroborated by esophagram, upper endoscopy, or both. Data were compared using Student's t test, χThe study identified 71 patients treated with minimally invasive esophagectomy: 35 patients with chemical pyloroplasty treated from September 2009 to January 2014 and 36 patients without pyloric intervention from February 2014 to June 2015. The groups were statistically similar in age, gender distribution, T stage, percentage of patients receiving neoadjuvant therapy, body mass index, preoperative weight loss, preoperative serum albumin, and preoperative placement of feeding tubes (all p 0.05). The overall incidence of delayed gastric emptying was low in both groups: 8.6% (3/35) of the patients with chemical pyloroplasty versus 5.6% (2/36) of the patients with no pyloric intervention (p = 0.62). The two groups also did not differ significantly in the development of aspiration pneumonia or the need for pyloric intervention.In a well-matched cohort study with a historical control group, use of botulinum toxin for chemical pyloroplasty in minimally invasive esophagectomies was not associated with improved outcomes related to the pylorus versus no pyloric intervention. Although preliminary, these data suggest that chemical pyloroplasty is not necessary in minimally invasive esophagectomy.

Background Initiatives exist to prevent pediatric injuries, but targeting these interventions to specific populations is challenging. We hypothesized that mapping pediatric injuries by zip code could be used to identify regions requiring more interventions and resources. Methods We queried the trauma registries of two level I trauma centers for children 0–17 years of age injured between 2009 and 2013 with home zip codes in our state. Maps were created to identify outlier zip codes. Multivariate linear regression analysis identified predictors within these zip codes. Results There were 5380 children who resided in the state and were admitted for traumatic injuries during the study period, with hospital costs totaling more than 200 million dollars. Choropleth mapping of patient addresses identified outlier zip codes in our metro area with higher incidences of specific mechanisms of injury and greater hospital charges. Multivariate analysis identified demographic features associated with higher rates of pediatric injuries and hospital charges, to further target interventions. Conclusions We identified outlier zip codes in our metro area with higher frequencies of pediatric injuries and higher costs for treatment. These data have helped obtain funding for prevention and education efforts. Techniques such as those presented here are becoming more important as evidence based public health initiatives expand. Level of evidence Type of Study: Cost Effectiveness, II.

Solid-pseudopapillary neoplasms are rare pancreatic neoplasms with low malignant potential that predominantly arise in young women. We sought to characterize this population and the evolving trend at our institution towards laparoscopic management. We identified all patients at our institution that were surgically treated for solid-pseudopapillary neoplasm from 2008-2015. Demographic and clinical information were queried from the medical record, and descriptive statistics were performed. Student’s t test and chi-square analysis were used for comparison where appropriate. We identified 11 women and 1 man (average age 26 years; range 14–48 years) who were surgically treated for solid-pseudopapillary neoplasms; 5 with distal pancreatectomy (4 open, 1 laparoscopic), 6 with pancreaticoduodenectomy (3 open, 3 laparoscopic), and 1 open enucleation. From 2008 to 2013, seven of eight (87 %) procedures were performed open. Since 2014, three of four (75 %) procedures have successfully been completed laparoscopically (see video clips). Length of stay was similar for patients who had open versus laparoscopic procedures (8 vs. 9 days, p = 0.61). Two-thirds of patients (5/8) who had open procedures experienced postoperative complications compared with half (2/4) of patients who had laparoscopic procedures (p = 0.28). There have been no recurrences. Minimally invasive surgical management of solid-pseudopapillary neoplasms is becoming more popular, can be performed safely, and appears to have comparable outcomes to an open approach. Quality of life is an important metric for this relatively young population and may be improved with a laparoscopic approach, which warrants further investigation.

Minimizing invasiveness is prevalent in nearly all aspects of surgery, and pancreatic surgery is no exception. Over the last two decades, laparoscopic pancreatic surgery has transitioned from experimental to becoming accepted within the standard of care, for procedures ranging from enucleation of pancreatic masses to distal pancreatectomy and, more recently, pancreaticoduodenectomy. Most reports of minimally invasive pancreatic surgery remain small, and thus few focus specifically on cystic neoplasms, but rather combine patients who received similar surgeries for a variety of indications. Cystic tumors of the pancreas lend themselves to minimally invasive management because they typically lack invasiveness to surrounding organs, are removed prophylactically in younger patients, and can be easily visualized laparoscopically.

Early tracheostomy has been advocated for adult trauma patients to improve outcomes and resource utilization. We hypothesized that timing of tracheostomy for severely injured children would similarly impact outcomes.Injured children undergoing tracheostomy over a 10-year period (2002-2012) were reviewed. Early tracheostomy was defined as post-injury day ≤ 7. Data were compared using Student's t test, Pearson chi-squared test and Fisher exact test. Statistical significance was set at p0.05 with 95% confidence intervals.During the 10-year study period, 91 patients underwent tracheostomy following injury. Twenty-nine (32%) patients were12 years old; of these, 38% received early tracheostomy. Sixty-two (68%) patients were age 13 to 18; of these, 52% underwent early tracheostomy. Patients undergoing early tracheostomy had fewer ventilator days (p=0.003), ICU days (p=0.003), hospital days (p=0.046), and tracheal complications (p=0.03) compared to late tracheostomy. There was no difference in pneumonia (p=0.48) between early and late tracheostomy.Children undergoing early tracheostomy had improved outcomes compared to those who underwent late tracheostomy. Early tracheostomy should be considered for the severely injured child.Early tracheostomy is advocated for adult trauma patients to improve patient comfort and resource utilization. In a review of 91 pediatric trauma patients undergoing tracheostomy, those undergoing tracheostomy on post-injury day ≤ 7 had fewer ventilator days, ICU days, hospital days, and tracheal complications compared to those undergoing tracheostomy after post-injury day 7.

Peritoneal dialysis (PD) is a common method of renal replacement therapy for children. However, placement of PD catheters has risk, and some are never used.We conducted a retrospective chart review of children with a PD catheter placed between 2000 and 2014. Logistic regression analyses were used to identify covariates associated with complications.We identified 175 children with PD catheters. 110 complications developed in 80 children (45.7%). Complications including unexpected return to the operating room and peritonitis increased as the length of time a catheter was in place increased. Children who weighed12.4 kg had 3.2 times greater odds of developing a leak (95% CI 1.21-8.63, p=0.02). Twelve children never used their PD catheters, 9 with acute kidney injury (AKI) who recovered from their disease more quickly than expected. No covariate was associated with nonuse.Complications with PD catheters are common and increase the longer catheters are in place. Lower weight children are at greater risk of PD catheter leak. Decreased initial volumes of dialysate in smaller children may mitigate this risk. Nonuse may be reduced if dialysis is permitted the day of placement for children with AKI.