Medicine and Health Sciences Commons^™

Impact Of Climate Change On Surgery: A Scoping Review To Define Existing Knowledge And Identify Gaps, Tina Bharani, Rebecca Achey, Harris Jamal, Alexis Cherry, Malcolm K. Robinson, Guy J. Maddern, Deirdre K. Tobias, Divyansh Agarwal

Department of Surgery Faculty Papers

With climate change accelerated at a worrisome rate, global warming also will have implications for surgery and surgical practice. The goal of this current study was to systematically survey the literature and better understand how climate change has affected surgical disease burden, surgical care delivery, and surgical outcomes. We performed a comprehensive scoping review, screening 3334 unique citations from three databases – 1766 from Embase, 1329 from Pubmed and 239 from Scopus – to identify studies that had associated climate change with surgery. After systematic searching, quality appraisal, and data extraction, we synthesized findings from qualitative and quantitative studies. Twenty-six …

A Multi-Institutional Analysis Of Sternoclavicular Joint Coverage Following Osteomyelitis, Sammy Othman, Omar Elfanagely, Saïd C Azoury, Geoffrey M Kozak, Jessica Cunning, Arturo J Rios-Diaz, Prashanth Palvannan, Patrick J. Greaney, Matthew Jenkins, Doraid Jarrar, Stephen J Kovach, John P Fischer

Department of Surgery Faculty Papers

BACKGROUND: Sternoclavicular joint (SCJ) osteomyelitis is a rare pathology requiring urgent intervention. Several operative approaches have been described with conflicting reports. Here, we present a multi-institutional study utilizing multiple surgical pathways for SCJ reconstruction.

METHODS: A multi-institutional retrospective cohort study was conducted to identify patients who underwent surgical repair for sternoclavicular osteomyelitis between 2008 and 2019. Patients were stratified according to reconstruction approach: single-stage reconstruction with advancement flap and delayed-reconstruction with flap following initial debridement. Demographics, operative approach, type of reconstruction, and postoperative outcomes were analyzed.

RESULTS: Thirty-two patients were identified. Mean patient age was 56.2±13.8 years and 68.8% were …

Extracorporeal Membranous Oxygenation Mimics Aortic Dissection On Cat Scan., Philip Batista, Nicholas C. Cavarocchi, Hitoshi Hirose

Department of Surgery Faculty Papers

A 66 year-old female presented with refractory acute congestive heart failure, cardiogenic shock, and ventricular tachyarrhythmia. Veno-arterial extracorporeal membrane oxygenation (ECMO) was placed via femoral cannulation for salvage and stabilized. CAT scan of the chest performed as a part of heart transplant work-up, demonstrated an unequal distribution of intravenous contrast in the aortic arch (Figure 1). Radiologist’s preliminary reading was of “aortic dissection” while in fact this is truly “normal ECMO flow”.

Successful Management Of Severe Liver Failure On Venoarterial Extracorporeal Membrane Oxygenation Using Molecular Adsorbent Recirculating Systeme., Shigeki Tabata, Nicholas Cavarocchi, Hitoshi Hirose

Department of Surgery Faculty Papers

A 49-year-old female with Adriamycin induced cardiomyopathy presented with decompensated biventricular congestive heart failure. Despite multiple Inotropes, the patient’s hemodynamics deteriorated and she underwent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) placement as a bridge to decision. Pre-ECMO workup showed liver dysfunction with elevated total bilirubin of 5.9 mg/dl, normal liver enzymes and liver ultrasound image. Tentative diagnosis of “end-stage liver failure” was made without a biopsy.

Shortly after initiation of ECMO, the patient developed massive hemoptysis which was successfully managed with continuation of ECMO and ventilator management. [i] The patient’s total bilirubin continued to increase to peak of 56 mg/dl on …

Parenthood With Exposure To Mycophenolic Acid Products, Sophia M. Termimi, Megan Clary, Lisa Coscia, Carolyn Mcgrory, Vincent T. Armenti

Department of Surgery Faculty Papers

Successful pregnancy outcomes have been reported in all solid-organ transplant recipients on a variety of immunosuppressive medication regimes. In October 2007, the FDA pregnancy category of mycophenolic acid products (MPA) was changed from category C to D, based on registry and post-marketing data which revealed a higher incidence of spontaneous abortions and structural birth defects. The purpose of this abstract is to describe pregnancy outcomes with exposure to MPA and pregnancies fathered by male transplant recipients conceived while taking MPA. Data were collected by the National Transportation Pregnancy Registry (NTPR) via questionnaires, telephone interview and medical records. There were 152 …

Evaluation Of The Use Of Patient-Focused Simulation For Student Assessment In A Surgery Clerkship., Gerald A Isenberg, Katherine W Berg, Judith A Veloski, Dale D Berg, J J. Veloski, Charles Yeo

Department of Surgery Faculty Papers

BACKGROUND: The purpose of this study was to evaluate the use of simulated patients in conjunction with anatomic and tissue task-training models to assess skills.

METHODS: Faculty reviewed the objectives of the clerkship to identify skills to be acquired. Three cases were developed related to rectal examination, suturing, and inserting intravenous lines and nasogastric tubes. Student scores were based on their ability to gather data from simulated patients and perform procedures on simulation models.

RESULTS: A total of 670 students were assessed between 2006 and 2009. Alpha reliability coefficients were .97 for Communication/Interpersonal Skills, .71 for Procedures, and .58 for …

Ercc1 And Rrm1 As Predictors Of Survival And Response In Pancreatic Ductal Adenocarcinoma Treated With Gemcitabine-Based Chemotherapy, Thomas Holdbrook, Kathleen D. Danenberg, Suneeta Satti, Jessica Kline, Charles J. Yeo, Jonathan R. Brody, Peter Mccue, Agnieszka K. Witkiewicz

Department of Surgery Faculty Papers

Conclusion:

In this study, we used RT-PCR and IHC to analyze RRM1 and ERCC1 mRNA and protein expression in PDA specimens. PDA patients with low expression of RRM1 by IHC derived benefit from gemcitabine-based chemotherapy. Assessment of RRM1 mRNA expression was limited by the small sample size. Low ERCC1 expression by RT-PCR was associated with a 2.5 times higher risk of mortality than high expression (p=0.031). There was no association between ERCC1 expression by IHC and survival; however, agreement between mRNA and protein expression was poor for ERCC1. This study demonstrates the ERCC1 and RRM1 expression have an impact on …

Ventral Hernia Repairs: 10 Year Single Institution Review At Thomas Jefferson University Hospital, Frederick C. Sailes, Md, Jason Walls, Md, Daria Guelig, Md, Mike Mirzabeigi, Ma, William D. Long, Ms, Albert Crawford, Phd, John H. Moore Jr, Md, Facs, Steven E. Copit, Md, Gary A. Tuma, M.D, James Fox, Md

Department of Surgery Faculty Papers

Abstract

Background Definitive repair of recurrent ventral hernias using abdominal wall reconstruction techniques is an essential tool in the armentarium for general and plastic surgeons. Ramirez 1 et al describes the “component separation” technique to mobilize the rectus-abdominus internal oblique and external oblique flap to correct the defect. The recurrence rate of incisional hernias increases to 20% after gastric bypass or extensive weight loss.2 The incidence of ventral hernias after failed recurrent hernia repair increases to 40%.3 It has been reported that utilizing the sliding myofascial flap repair technique, the recurrence rate was reduced to 8.5%.4

Materials and Methods This …

Pregnancy Outcomes In Female Liver Transplant Recipients With A Transplant-To-Conception Interval >- 5 Years, Carlo B. Ramirez, Adam Frank, Warren R. Maley, Cataldo Doria, Lisa A. Coscia, Vincent T. Armenti

Department of Surgery Faculty Papers

Conclusions: Successful pregnancy outcomes have been reported in female liver recipients with a transplant-to-conception interval greater than or equal to 5 years. Long-term graft survival should be discussed with recipients as a component of preconception counseling. All transplant centers are encouraged to report pregnancies to the NTPR.

Immunosuppressive Therapy For Autoimmune Disease And Pregnancy Outcomes, Karolina Paziana, Faith Carlin, Lisa A. Corcia, Carolyn H. Mcgrory, Dawn Armenti, Vincent T. Armenti

Department of Surgery Faculty Papers

Conclusions:

Cyclosporine exposure during pregnancy in the transplant population does appear to be associated with premature delivery and low infant birthweight.

Data from the NPR show that cyclosporine exposure during pregnancy in women with psoriasis does not appear to be associated with low gestational age or low infant birthweight.

Maternal comorbidities or other factors, such as multiple drug regimens, likely play a role in the higher rates of premature delivery and low birthweight infants in the kidney transplant population.

Further investigation is warranted to evaluate the impact of comorbidities and other factors on pregnancy outcomes of women taking Neoral®.

Solid-Organ Transplant Recipients And Breastfeeding While On Immunosuppression, Schweta Arakali, Faith Carlin, Lisa A. Coscia, Carolyn H. Mcgrory, Dawn Armenti, Vincent T. Armenti

Department of Surgery Faculty Papers

Conclusions:

The relatively small amount of drug transferred in breast milk and the lack of reported adverse effects along with the known benefits of breastfeeding may outweigh the risk of drug exposures in the transplant population.

The threshold for determining the level of exposure of an immunosuppressive agent that is acceptable is not known at present.

Continued study and follow-up of all breast-fed transplant recipient offspring is warranted.

Centers are encouraged to report all pregnancies in transplant recipients to the NTRR.

Pregnancy Outcomes With Exposure To The Mycophenolic Acid Products (Mpa), To Dung K. Nguyen, Faith Carlin, Lisa A. Coscia, Dawn Armenti, Vincent T. Armenti

Department of Surgery Faculty Papers

Conclusions:

Reports to NTPR to date continue to reveal an increased incidence of birth defects in transplant recipients maintained on MPA products during gestation compared to those not maintained on these agents.

Structural birth defects consisting of microtia (ear deformity) and facial defects suggest a pattern of malformations.

Evaluation of the higher incidence of non-viable outcomes requires further study in this cohort.

Centers are encouraged to report all pregnancy exposures in transplant recipients to the NTPR.

The Type 1 Insulin-Like Growth Factor Receptor In Hepatocellular Carcinoma Cell Lines, Zhengyu Wei, Phd, Tiziana Deangelis, M.S., Reginald Hurtt, B.S., Renato Baserga, M.D., Cataldo Doria, M.D., Ph.D

Department of Surgery Faculty Papers

Summary:

1. Human HCC cells have higher expression levels of IGF-1R, IRS1, and c-Met.

2. IRS1 interacts with c-Met. The role of IGF-1R in human HCC should be revisited.

3. Lentivirus-mediated shRNA delivery system targeting IGF-1R showed significant suppressive effects on HCC cell growth, promising a potential therapeutic treatment for human HCC.

Pregnancy Outcomes In Female Liver Recipients Transplanted Under The Age Of 21, Carlo B. Ramirez, Warren R. Maley, Cataldo Doria, Lisa A. Coscia, Michael J. Moritz, Vincent T. Armenti

Department of Surgery Faculty Papers

Conclusions: Liver recipients transplanted under the age of 21 are able to maintain pregnancy with 75% resulting in a livebirth. Pregnancy, potential risks for mother and newborn, and long-term maternal survival should be discussed with the recipient and the parents of the recipient. Transplant centers are encouraged to report pregnancy outcomes in these recipients to the NTPR.

Pregnancy Outcomes In Female Lung Transplant Recipients, Julie Shaner, Faith Carlin, Lisa A. Coscia, Carolyn H. Mcgrory, Dawn Armenti, Vincent T. Armenti

Department of Surgery Faculty Papers

Conclusions:

Female lung recipients appear to face higher risks related to pregnancy when compared to other solid organ transplant recipients.

Although successful pregnancies have been reported in female lung recipients, analyses of larger numbers of cases may help to identify pre-pregnancy factors predictive of adverse outcomes.

Centers are encouraged to report all pregnancies in transplant recipients to the NTPR.

Pregnancy Outcomes In Pancreas-Kidney Vs. Kidney-Alone Diabetic Female Transplant Recipients, Lyuba Gitman, Faith Carlin, Lisa A. Coscia, Carolyn H. Mcgrory, Dawn Armenti, Vincent T. Armenti

Department of Surgery Faculty Papers

Conclusions:

The high incidences of hypertension, preeclampsia, and infection during pregnancy underscore the high-risk nature of pregnancy in both pancreas-kidney and kidney alone recipients.

Although overall offspring outcomes are similar in both PK and K groups, pregnancy in PK recipients may be associated with higher incidences of maternal infections and overall graft loss.

Centers are encouraged to report all pregnancies in transplant recipients to the NTPR.

Metastatic Disease To The Pancreas And Spleen, Shayna L. Showalter, Eric Hager, Charles J. Yeo

Department of Surgery Faculty Papers

Isolated metastases to the pancreas and spleen are a rare occurrence. When they are diagnosed, pancreatic metastases are most often from renal cell carcinoma, lung cancer, and breast cancer. The most common source of splenic metastases is gynecological in origin; the overwhelming majority is ovarian. If extensive staging studies reveal these metastases to be isolated, then curative resection may be warranted. This review will demonstrate that long-term survival may be achieved in patients with isolated metastases and a prolonged disease-free interval.

Comparison Of Eight Prosthetic Aortic Valves In A Cadaver Model, Benjamin A. Youdelman, Hitoshi Hirose, Harsh Jain, J. Yasha Kresh, John W.C. Entwhistle Iii, Andrew S. Wechsler

Department of Surgery Faculty Papers

OBJECTIVES: Proper valve selection is critical to ensure appropriate valve replacement for patients, because implantation of a small valve might place the patient at risk for persistent gradients. Labeled valve size is not the same as millimeter measure of prosthetic valve diameters or the annulus into which it will fit. Studies that use the labeled valve size in lieu of actual measured diameter in millimeters to compare different valves might be misleading. Using human cadaver hearts, we sized the aortic annulus with 8 commonly used prosthetic aortic valve sizers and compared the valves using geometric orifice area. This novel method …

Resected Serous Cystic Neoplasms Of The Pancreas: Locally Aggressive Behavior As A Predictor Of Malignant Disease? A Review Of 158 Patients With Recommendations For Treatment., Charles Galanis, Amir Zamani, John L. Cameron, Kurtis A. Campbell, Keith D. Lillemoe, David Caparrelli, David Chang, Ralph H. Hruban, Charles Yeo

Department of Surgery Faculty Papers

Background: Serous cystic neoplasms of the pancreas are regarded as a benign entity with rare malignant potential. Surgical resection is generally considered curative. Objective: To perform the largest single institution review of patients who underwent surgical resection for serous cystic neoplasms of the pancreas in the hopes of guiding future management. Methods: Between June 1988 and January 2005, 158 patients with serous cystic neoplasms of the pancreas underwent surgical resection. A retrospective analysis was performed. Univariate and multivariate models were used to determine factors influencing perioperative morbidity and mortality. Major complications were defined as pancreatic fistula or anastomotic leak, postoperative …

Gangliocytic Paraganglioma: Case Report And Review Of The Literature, Agnes Witkiewicz, Avi Galler, Charles Yeo

Department of Surgery Faculty Papers

Gangliocytic paraganglioma is a rare tumor, which occurs nearly exclusively in the second portion of the duodenum. Generally, this tumor has a benign clinical course, although rarely, it may recur or metastasize to regional lymph nodes. Only one case with distant metastasis has been reported. We present a case of duodenal gangliocytic paraganglioma treated first by local resection followed by pylorus-preserving pancreaticoduodenectomy. Examination of the first specimen revealed focal nuclear pleomorphism and mitotic activity, in addition to the presence of three characteristic histologic components: epithelioid, ganglion, and spindle cell. In the subsequent pancreaticoduodenectomy specimen, there was no residual tumor identified …