Blunt impact-induced traumatic abdominal wall hernia (TAWH) is an uncommon pediatric surgical problem classically associated with handlebar injury but increasingly seen with seatbelt use in motor vehicle collisions (MVC). Herein we describe the largest case series of pediatric TAWH to date and review the literature to establish the unique syndromic characteristics of MVC-associated TAWH. In this single-institution series, we discuss four pediatric patients, all with seatbelt-associated TAWH after high-speed MVC characterized by full-thickness disruption of the lateral abdominal wall. We then performed a review of the literature to identify additional pediatric MVC-associated TAWH and define the characteristics of patients who sustained this unique injury. In addition to the four patients in our case series, five additional pediatric patients presenting with TAWH after restrained MVC were identified in the literature. Of these nine patients, eight (89%) presented with an obvious seatbelt sign (bruising/laceration to the abdominal wall). Six (67%) had associated injuries typical of the seatbelt syndrome, including four spinal flexion injuries (44%) and five bowel injuries requiring repair or resection (56%). Overall, 56% of seatbelt-associated TAWH occurred in children with a BMI percentile > 95%. In this case series and literature review, we note a high rate of seatbelt syndrome injuries in pediatric patients presenting with TAWH after restrained MVC. Suspicion for TAWH should be high in children presenting with a seatbelt sign and should trigger a low threshold for pursuing additional axial imaging. Level IV; case series.

Decannulation from pediatric veno-arterial extracorporeal membrane oxygenation (VA-ECMO) involves the removal of large arterial perfusion cannulas from relatively small lower extremity arteries. While these challenging repairs are frequently performed by general pediatric surgeons, there is little standardization with regard to vascular techniques within the pediatric surgery training paradigm, resulting in variability in the repair of these arteriotomies and potential future consequences for lower extremity perfusion and growth. Herein we present a technique for repair of large common femoral arteriotomies following removal of ECMO perfusion cannulas utilizing a dual-layer patch of ipsilateral saphenous vein harvested via the arterial cutdown incision. This vein segment is everted to maximize endothelial surface area of the patch and dual layered to provide additional support against aneurysmal degeneration. The described technique is an effective repair of arteriotomy following VA-ECMO decannulation, which minimizes vascular complications and is an accessible technique to those without advanced vascular surgical training. LEVEL OF EVIDENCE: Level IV; operative technique description with small case series.

Objective: To examine the association between prolonged in-hospital time to appendectomy (TTA) and the risk of complicated appendicitis. Summary Background Data: Historically, acute appendicitis was treated with emergency appendectomy. More recently, practice patterns have shifted to urgent appendectomy, with acceptable in-hospital delays of up to 24 hours. However, the consequences of prolonged TTA remain poorly understood. Herein, we present the largest individual analysis to date of outcomes associated with prolonged in-hospital delay before appendectomy in children. Methods: Data from patients who underwent appendectomy within 24 hours of hospital presentation were obtained from the American College of Surgeons Pediatric National Surgical Quality Improvement Program Procedure Targeted Appendectomy database from 2016 to 2018. Appendectomy within 16 hours of presentation was considered early, whereas those between 16 to 24 hours were defined as late. The primary outcome was operative findings of complicated appendicitis. Secondary outcomes included 30-day complications and resource utilization. Results: This study consisted of 18,927 patients, with 20.6% undergoing late appendectomy. The rate of complicated appendicitis was significantly higher in the late group (Early: 26.3%, Late: 30.3%, P < 0.05). Additionally, the late group had longer operative times, increased need for postoperative percutaneous drainage, antibiotics at discharge, parenteral nutrition, and an extended hospital length of stay (P < 0.05). On multivariate analysis, late appendectomy remained a predictor of complicated disease (odds ratio 1.17 [95% confidence interval, 1.08–1.27]). Conclusions: A significant proportion of pediatric patients with acute appendicitis experience prolonged in-hospital delays before appendectomy, which are associated with modestly increased rates of complicated appendicitis. Although this does not indicate appendectomy needs to be done emergently, prolonged in-hospital TTA should be avoided whenever possible.

Cooper, C Randall MD; Pedroso, Felipe E. MD, MPH; Hochman, Beth R. MD; Arnell, Tracey D. MD Author Information

Of adolescents in the United States, 20% have obesity and current treatment options prioritize intensive lifestyle interventions that are largely ineffective. Bariatric surgery is increasingly being offered to obese adolescent patients; however, large-scale effectiveness data is lacking. We used MEDLINE, Embase, and Cochrane databases, and a manual search of references to conduct a systematic review and meta-analysis on overall weight loss after gastric band, gastric sleeve, and gastric bypass in obese adolescent patients (age ≤19) and young adults (age ≤21) in separate analyses. We provided estimates of absolute change in body mass index (BMI, kg/m2) and percent excess weight loss across 4 postoperative time points (6, 12, 24, and 36 mo) for each surgical subgroup. Study quality was assessed using a 10 category scoring system. Data were extracted from 24 studies with 4 having multiple surgical subgroups (1 with 3, and 3 with 2 subgroups), totaling 29 surgical subgroup populations (gastric band: 16, gastric sleeve: 5, gastric bypass: 8), and 1928 patients (gastric band: 1010, gastric sleeve: 139, gastric bypass: 779). Mean preoperative BMI (kg/m2) was 45.5 (95% confidence interval [CI]: 44.7, 46.3) in gastric band, 48.8 (95%CI: 44.9, 52.8) in gastric sleeve, and 53.3 (95%CI: 50.2, 56.4) in gastric bypass patients. The short-term weight loss, measured as mean (95%CI) absolute change in BMI (kg/m2) at 6 months, was –5.4 (−3.0, −7.8) after gastric band, −11.5 (−8.8, −14.2) after gastric sleeve, and −18.8 (−10.9, −26.6) after gastric bypass. Weight loss at 36 months, measured as mean (95%CI) absolute change in BMI (kg/m2) was −10.3 (−7.0, −13.7) after gastric band, −13.0 (−11.0, −15.0) after gastric sleeve, and −15.0 (−13.5, −16.5) after gastric bypass. Bariatric surgery in obese adolescent patients is effective in achieving short-term and sustained weight loss at 36 months; however, long-term data remains necessary to better understand its long-term efficacy.

OBJECTIVE:Chronic treatment with antipsychotics may result in both metabolic side effects and cardiovascular disease. Our aim was to evaluate the effect of antipsychotic medications categorized by their metabolic side effect profiles as low, intermediate, or high risk on major cardiovascular events.METHODS:A retrospective cohort study was conducted in adult outpatients aged 30 years or older initiating antipsychotic treatment from 2002 to 2007. Antipsychotic medications were divided into 3 groups (low-, intermediate-, and high-risk) according to the severity of their side-effect profiles in developing metabolic abnormalities associated with cardiovascular disease. The primary outcome measure was the time to the composite of acute myocardial infarction, acute coronary syndrome, ischemic stroke, peripheral artery disease, or a new revascularization procedure. Inverse probability weighting of a marginal structural Cox model was used to adjust for confounding.RESULTS:A total of 1,008 patients were included (mean age = 72.4 years, median follow-up = 36.5 months), and 19.6% of patients experienced the primary outcome. The adjusted hazard ratios of a major cardiovascular event for patients in the high- or intermediate-risk medication groups compared to the low-risk group were 2.82 (95% CI, 1.57-5.05) and 2.57 (95% CI, 1.43-4.63), respectively.CONCLUSIONS:Older adult patients under antipsychotic regimens with high or intermediate risk of metabolic side effects may face a higher incidence of major cardiovascular events than those under a low-risk regimen during long-term follow-up.

Objectives. To evaluate changes in bicycle use and cyclist safety in Boston, Massachusetts, following the rapid expansion of its bicycle infrastructure between 2007 and 2014.Methods. We measured bicycle lane mileage, a surrogate for bicycle infrastructure expansion, and quantified total estimated number of commuters. In addition, we calculated the number of reported bicycle accidents from 2009 to 2012. Bicycle accident and injury trends over time were assessed via generalized linear models. Multivariable logistic regression was used to examine factors associated with bicycle injuries.Results. Boston increased its total bicycle lane mileage from 0.034 miles in 2007 to 92.2 miles in 2014 (P<.001). The percentage of bicycle commuters increased from 0.9% in 2005 to 2.4% in 2014 (P=.002) and the total percentage of bicycle accidents involving injuries diminished significantly, from 82.7% in 2009 to 74.6% in 2012. The multivariable logistic regression analysis showed that for every 1-year increase in time from 2009 to 2012, there was a 14% reduction in the odds of being injured in an accident.Conclusions. The expansion of Boston's bicycle infrastructure was associated with increases in both bicycle use and cyclist safety.

Burns cause chronic inflammation and hypermetabolism, with muscle wasting and organomegaly. Myostatin is a tonic inhibitor of muscle growth. Myostatin and the closely related ligands Activins and GDF-11 can induce wasting and have been implicated cancer cachexia. We evaluated inhibitors of differential specificity to preserve muscle mass.

BACKGROUND:Bariatric surgery has shown to be an effective weight loss treatment in morbidly obese adolescents. We compared outcomes of laparoscopic adjustable gastric band (LAGB) to laparoscopic vertical sleeve gastrectomy (VSG).METHODS:A single institution, retrospective evaluation of a prospectively collected database of LAGB and VSG patients.RESULTS:174 morbidly obese patients underwent bariatric surgery at our institution between 2006 and 2013. 137 patients underwent LAGB and 37 underwent VSG. There were no significant differences between LAGB vs. VSG groups on day of surgery for age, gender, ethnicity, weight, and BMI. At 24-month follow up, patients who underwent VSG vs. LAGB displayed significantly greater percent excess weight loss (70.9±20.7 vs. 35.5±28.6, P=0.004) and percent preoperative BMI loss (32.3±11.0 vs. 16.4±12.7, P=0.004). Both VSG and LAGB significantly improved levels of HDL, HgA1c, and fasting glucose. LAGB patients had more complications than VSG patients.CONCLUSION:Bariatric surgery is an effective treatment strategy in morbidly obese adolescents who have failed medical management. VSG results in greater short term weight and BMI loss when compared to LAGB. Longer follow up with more patients will be required to confirm the long term safety and efficacy of VSG in adolescent patients.

There is no consensus on the most effective modality for the treatment of resectable esophageal adenocarcinomas (EAC). We theorized that treatment modality may influence survival differently depending on the stage of disease.

Burn injury results in a chronic inflammatory, hypermetabolic, and hypercatabolic state persisting long after initial injury and wound healing. Burn survivors experience a profound and prolonged loss of lean body mass, fat mass, and bone mineral density, associated with significant morbidity and reduced quality of life. Understanding the mechanisms responsible is essential for developing therapies. A complete characterization of the pathophysiology of burn cachexia in a reproducible mouse model was lacking.

Whether liver resection or liver transplantation is optimal therapy for patients with hepatocellular carcinoma (HCC) remains undefined. A meta-analysis was conducted to answer this question.

Background The role of neoadjuvant and adjuvant therapy for gastric cancer remains undefined. We compared the outcomes for patients treated with surgery alone or with the addition of adjuvant or neaodjuvant treatment. Methods A single-institution, retrospective evaluation of a prospective database of gastric cancer patients treated from 2000 to 2008 was performed. Results Overall, 173 patients with gastric cancer underwent surgical extirpation. Of the 173 patients, 43% had early-stage disease (less than stage 2) and 57% had late-stage disease (stage 2 or greater; American Joint Committee on Cancer, 2010). The median survival from the date of diagnosis for those treated with neoadjuvant chemotherapy (NAC) (n = 35), adjuvant chemotherapy (n = 21), adjuvant chemoradiotherapy (n = 18), both NAC and adjuvant chemotherapy (n = 11), or surgery alone (n = 88) was 26.3, 17.3, greater than 60, greater than 60, and 50.3 months, respectively. The addition of NAC to surgery was detrimental to survival in those with early-stage disease (P = 0.002) and did not improve survival in those with late-stage disease (P = 0.687). For those with late-stage disease, surgery with adjuvant chemoradiotherapy exhibited the best overall survival compared with surgery alone (P = 0.021) or surgery with adjuvant chemotherapy (P = 0.01). Patients treated with NAC had a greater rate of R0 resection compared with surgery alone (P = 0.049). Conclusions NAC for patients with gastric cancer does not significantly improve the overall outcomes for those with late-stage disease and could be detrimental to survival for those with early-stage disease. However, treatment with NAC resulted in an improved rate of R0 resection.

BACKGROUND:Tyrosine kinase inhibitor (TKI) therapy for patients with gastrointestinal stromal tumors (GISTs) has been shown to improve overall outcomes. It remains unclear whether TKIs are delaying tumor recurrence or actually affecting cure rates. We sought to determine whether changes in overall and disease-specific survival (OS and DSS, respectively) for patients with surgically resected gastric GISTs have been observed after the introduction of TKI therapies by using population-based data.METHODS:The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients with resected gastric mesenchymal tumors before the introduction of TKIs (pre-TKI: 1990–1994) and after their inception (post-TKI: 2002–2003).RESULTS:Overall, 594 patients with gastric mesenchymal tumors were identified, and 189 and 405 underwent resection in the pre- and post-TKI eras, respectively. Between groups, there were no significant differences in patient demographics. The 1- and 6-year OS improved from 84 and 36 to 93 and 71%, respectively. The 1- and 6-year DSS improved from 92 and 62 to 96 and 90%, respectively. Through 6 years, OS and DSS significantly improved for all stages, tumor sizes, and extent of operation. By using multivariate analysis, undergoing treatment in the pre-TKI era was an independent negative predictor of OS, hazard ratio (HR, 2.98) and DSS (HR, 3.81).CONCLUSIONS:The TKI era is associated with dramatic improvements in OS and DSS for patients with surgically resected gastric GISTs, irrespective of stage, tumor size, and extent of operation through 6 years of follow-up. It remains unclear, however, whether this survival advantage is a change in cure rate or simply a delay in disease progression.

It has been suggested by some authors that surgically placed portacaval shunts not be performed in alcoholic patients due to increased complication rates. This notion has been based primarily on retrospective analyses, with little prospective randomized data to examine this question. In the 5th report of the San Diego Bleeding Esophageal Varices Study, a prospectively randomized trial, Orloff and colleagues have demonstrated in subset analysis that emergency portacaval shunting (EPCS) can be an effective treatment for portal hypertension in both alcoholics and nonalcoholics. The study showed no statistically significant difference in the number of packed red blood cells used, 5-y survival, recurrence of portal-systemic encephalopathy, or total charges incurred per year as well as throughout the study period in both alcoholics and nonalcoholics. The study also showed for the first time a significantly greater improvement in liver function following EPCS in alcoholic versus nonalcoholic cirrhotics [ 1 Orloff M.J. Isenberg J.I. Wheeler H.O. et al. Alcoholic versus nonalcoholic cirrhosis in a randomized controlled trial of emergency therapy of bleeding varices. J Surg Res. 2010; (in press) PubMed Google Scholar ].

Objective: To compare outcomes for patients with hepatocellular carcinoma (HCC) treated with either liver resection or transplantation.Methods: A retrospective, single-institution analysis of 413 HCC patients from 1999 to 2009.Results: A total of 413 patients with HCC underwent surgical resection (n = 106) and transplantation (n = 270) or were listed without receiving transplantation (n = 37). Excluding transplanted patients with incidental tumors (n = 50), 257 patients with suspected HCC were listed with the intent to transplant (ITT). The median diameter of the largest tumor by radiography was 6.0 cm in resected, 3.0 cm in transplanted, and 3.4 cm in the listed-but-not-transplanted patients. Median time to transplant was 48 days. Recurrence rates were 19.8% for resection and 12.1% for all ITT patients. Overall, patient survival for resection versus ITT patients was similar (5-year survival of 53.0% vs 52.0%, not significant). However, for HCC patients with model end-stage liver disease (MELD) scores less than 10 and who radiologically met Milan or UCSF (University of California, San Francisco) criteria, 1-year and 5-year survival rates were significantly improved in resected patients. For patients with MELD score less than 10 and who met Milan criteria, 1-year and 5-year survival were 92.0% and 63.0% for resection (n = 26) versus 83.0% and 41.0% for ITT (n = 73, P = 0.036). For those with MELD score less than 10 and met UCSF criteria, 1-year and 5-year survival was 94.0% and 62.0% for resection (n = 33) versus 81.0% and 40.0% for ITT (n = 78, P = 0.027).Conclusions: Among known HCC patients with preserved liver function, resection was associated with superior patient survival versus transplantation. These results suggest that surgical resection should remain the first line therapy for patients with HCC and compensated liver function who are candidates for resection.

Background. Lung cancer is the second most common neoplasm and the leading cause of cancer deaths in the United States. In cancer, weight loss and obesity are associated with reduced survival. However, the effect of obesity or weight loss at presentation on lung cancer survival has not been well studied.Materials and Methods. Using an extensive cancer dataset, we identified 76,086 patients diagnosed with lung cancer during the period of 1998-2002, of which 14,751 patients presented with obesity and/or weight loss. We examined the relationship between survival and weight loss or obesity at diagnosis using univariate and multivariate analysis.Results. Median survival time (MST) for all lung cancer patients was 8.7 mo. Patients presenting with weight loss (15.8%) had shorter MST versus those who did not (6.4 versus 9.2 mo, P < 0.001) and patients with weight loss had significantly shortened MST for all stages and histologic subtypes. In contrast, obese patients at presentation (5.4%) had longer MST relative to non-obese patients (13.0 versus 8.6 mo, P < 0.001), which was significant across all stages and histologic subtypes. Multivariate analysis revealed that the absence of weight loss was an independent, positive predictor of improved survival (HR = 0.087, P < 0.001), while the absence of obesity was an independent predictor of worsened survival in lung cancer (HR = 1.16, P < 0.001).Conclusions. Our results demonstrate an inverse relationship between survival and weight loss at presentation and a potentially protective effect of obesity in lung cancer survival, which could be due to greater physiologic reserves, thereby prolonging life by slowing the progress of cancer cachexia. (C) 2011 Elsevier Inc. All rights reserved.

Objective: The objective of this study is to determine outcomes of pediatric patients with primary gastrointestinal tract lymphoma (PGTL) and the impact of surgery or radiation on survival.Methods: The Surveillance, Epidemiology, and End Result database was queried from 1973 to 2006 for patients younger than 20 years with PGTL.Results: 265 patients with PGTL were identified. Overall 5- and 10-year survivals were 84% and 83%, respectively. Tumors of the stomach (9%) and rectum/anus (2%) had the worst and best 10-year survivals, respectively (59% vs 100%, P=.023). There was no significant difference in 10-year survival for patients younger than 10 years of age who had surgical extirpation (83% vs 85% no surgery, P=.958) or radiotherapy (76% vs 85% no radiotherapy, P=.532). However, there was a significantly decreased 10-year survival in patients 10 years or older who had surgical extirpation (79% vs 100% no surgery, P=.013) or radiotherapy (49% vs 87% no radiotherapy, P=.001). Under multivariate analysis, tumor location was an independent predictor of improved survival (small bowel, HR 0.21, P=.002; large bowel, HR 0.23, P=.004).Conclusion: We found no significant survival advantage for surgical extirpation or radiotherapy in patients younger than 10 years with PGTL, whereas either treatment modality was associated with lower survival in patients 10 years or older. (C) 2011 Elsevier Inc. All rights reserved.