Surgery Commons^™

Successful Surgical Intervention Of Total Anomalous Pulmonary Venous Drainage In The Third Decade Of Life, Awais Ashfaq, Nilay Shah, Mubashir Z. Khan, Mehnaz Atiq, Muneer Amanullah

Department of Surgery Docs

Total anomalous pulmonary venous drainage (TAPVD) accounts for approximately 1.5% of all congenital heart diseases. It is usually diagnosed in the neonatal period and is rarely seen in adults. We report an unusual case of a patient with TAPVD who was successfully treated at the age of 28 years. We believe that this is the oldest person in the South Asian literature to undergo surgical correction of TAPVD.

Clinical Outcomes Of Surgically Corrected Atrial Septal Defects, Waleed Tariq Siddiqui, Shazia Parveen, Maria Tariq Siddiqui, Muneer Amanullah

Department of Surgery Docs

Objective: To examine the outcomes of surgical repair of atrial septal defects in paediatric and adult patients.
Methods: The retrospective study comprised data of 84 patients who had undergone surgical correction of atrial septal defect at the Aga Khan University Hospital, Karachi, between June 2006 and December 2011. All patients with isolated atrial septal defect (ostium secundum, ostium primum and sinus venosus with or without partial anomalous pulmonary venous connection) were included. Clinical and transthoracic echocardiographic data was reviewed. SPSS 17 was used for statistical analysis.
Results: There were no deaths in the study population. The mean time for follow-up …

Advanced Augmented Reality Telestration Techniques With Applications In Laparoscopic And Robotic Surgery, Stephen Dworzecki

Wayne State University Dissertations

The art of teaching laparoscopic or robotic surgery currently has a primary reliance on an expert surgeon tutoring a student during a live surgery. During these operations, surgeons are viewing the inside of the body through a manipulatable camera. Due to the viewpoint translation and narrow field of view, these techniques have a substantial learning curve in order to gain the mastery necessary to operate safely. In addition to moving and rotating the camera, the surgeon must also manipulate tools inserted into the body. These tools are only visible on camera, and pass through a pivot point on the body …

Open Versus Laparoscopic Hiatal Hernia Repair., Terrence M. Fullum, Tolulope A. Oyetunji, Gezzer Ortega, Daniel D. Tran, Ian M. Woods, Olusola Obayomi-Davies, Orighomisan Pessu, Stephanie R. Downing, Edward E. Cornwell

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: The literature reports the efficacy of the laparoscopic approach to paraesophageal hiatal hernia repair. However, its adoption as the preferred surgical approach and the risks associated with paraesophageal hiatal hernia repair have not been reviewed in a large database.

METHOD: The Nationwide Inpatient Sample dataset was queried from 1998 to 2005 for patients who underwent repair of a complicated (the entire stomach moves into the chest cavity) versus uncomplicated (only the upper part of the stomach protrudes into the chest) paraesophageal hiatal hernia via the laparoscopic, open abdominal, or open thoracic approach. A multivariate analysis was performed controlling for …

The Role Of Bridging Therapy In Hepatocellular Carcinoma, Roberto Galuppo, Angie Mccall, Roberto Gedaly

Surgery Faculty Publications

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver accounting for 7% of all cancers worldwide. Most cases of HCC develop within an established background of chronic liver disease. For that reason, liver resection is only possible in selected patients. Liver transplantation has become the treatment of choice in patients with HCC, end-stage liver disease, and significant portal hypertension. Shortage of organ donors has resulted in overall increase of waiting list time with increased risk of dropout due to tumor progression. Neoadjuvant therapies have emerged as an alternative to control tumor growth in patients while waiting. The …

Evaluation Of Echo Ps Positioning System In A Porcine Model Of Simulated Laparoscopic Ventral Hernia Repair, Erin M. Hanna, Guy R. Voeller, J. Scott Roth, Jeffrey R. Scott, Darcy H. Gagne, David A. Iannitti

Surgery Faculty Publications

Purpose. Operative efficiency improvements for laparoscopic ventral hernia repair (LVHR) have focused on reducing operative time while maintaining overall repair efficacy. Our objective was to evaluate procedure time and positioning accuracy of an inflatable mesh positioning device (Echo PS Positioning System), as compared to a standard transfascial suture technique, using a porcine model of simulated LVHR. Methods. The study population consisted of seventeen general surgeons (n = 17) that performed simulated LVHR on seventeen (n = 17) female Yorkshire pigs using two implantation techniques: (1) Ventralight ST Mesh + Echo PS Positioning System (Echo PS) and …

A 22-Year-Old Female With Invasive Epithelioid Angiomyolipoma And Tumor Thrombus Into The Inferior Vena Cava: Case Report And Literature Review, Campbell Grant, John M. Lacy, Stephen E Strup

Surgery Faculty Publications

A 22-year-old female presented with back pain and was discovered to have a right-sided abdominal mass. Computed tomography (CT) scan revealed a 9 cm enhancing right upper pole renal mass with suspicion for tumor thrombus into the right renal vein and possibly the inferior vena cava (IVC). Magnetic resonance imaging (MRI) confirmed tumor thrombus into the inferior vena cava approximately 3 cm below the hepatic venous confluence. Open right radical nephrectomy with inferior vena cava thrombectomy was performed with removal of right kidney and tumor thrombus en bloc. Pathology revealed malignant epithelioid angiomyolipoma (EAML or PEComa). Epithelioid angiomyolipoma is a …

The Effectiveness Of An Abbreviated Training Program For Health Workers In Breast Cancer Awareness: Innovative Strategies For Resource Constrained Environments, Miriam Mutebi, Ronald Wasike, Ahmed Mushtaq, Aideed Kahie, Stephen Ntoburi

General Surgery, East Africa

Background: Breast cancer is characterized by late presentation and significant morbidity and mortality in developing countries. Breast screening aids in early detection of breast cancer. Nurses are uniquely placed to provide advocacy and screening in a resource limited environment.

Objectives: To assess the effectiveness of an abbreviated training program in breast cancer awareness on nurses at a tertiary hospital, in a resource constrained environment.

Methods: Using a statistical tool, the Solomon Model, 79 nurses were identified and divided into experimental and control groups. An abbreviated training intervention in breast cancer awareness was administered to the experimental group. Pre and post …

An Analysis Of The Educational Value And Impact Of A Dual, Versus Single, Robotic Surgical Console In The Training Of Obgyn Residents, Joseph E. Patruno Md, Hubert K. Huang Ms, Med, Michelle W. Huang Md, Thomas Hutchinson Md, Martin A. Martino Md

Department of Obstetrics & Gynecology

No abstract provided.

Tuberculosis Verrucosa Cutis In A Patient With Keloid Over Ear Lobule, Muhammad Sohail Halim, Sadaf Qadeer Ahmed, Montasir Junaid, Muhammad Rizwan Bashir

Section of Otolaryngology, Head & Neck Surgery

Tuberculosis (TB) is a global health problem with predominance in resource-poor countries. Extrapulmonary TB constitutes approximately 10% of the cases and can present as different forms depending on the route of entry. Cutaneous TB is a small subset of the extrapulmonary TB. Cutaneous TB can either be of primary origin or secondary origin or it can be a part of a systemic infection. TB verrucosa cutis (TBVC) is the exogenous reinfection of TB in a previously sensitised patient. Routine cultures do not have a high yield in TBVC due to the paucibacillary nature of the organism. Here we are presenting …

Targeted Therapies In The Treatment Of Advanced Hepatocellular Carcinoma., Zhengyu Wei, Cataldo Doria, Yuan Liu

Department of Surgery Faculty Papers

Hepatocellular carcinoma (HCC) is the most common liver cancer and the third leading cause of cancer death. It has been a major worldwide health problem with more new cases being diagnosed each year. The current available therapies for patients with advanced HCC are extremely limited. Therefore, it is of great clinical interests to develop more effective therapies for systemic treatment of advanced HCC. Several promising target-based drugs have been tested in a number of clinical trials. One breakthrough of these efforts is the approved clinical use of sorafenib in patients with advanced HCC. Targeted therapies are becoming an attractive option …

Incidence And Quality Implications Of Deep Venous Thrombosis After Peripherally Inserted Central Venous Catheter, Shawn Travis Greathouse Md, Jarom N. Gilstrap Md, Ramon Garza, Iii Md, Kimberly Reinart Rn, Holly Tavianini Rn, Bsn, Mshsa, Cnrn, Vera Deacon Rn, Crni, Robert X. Murphy Jr, Md, Ms

Department of Surgery

No abstract provided.

Midterm Results Of Bovine Jugular Vein Conduit For Right Ventricular Outflow Tract Reconstruction, Shazia Samad Mohsin, Maria Tariq Siddiqui, Abdul Sattar Shaikh, Mehnaz Atiq, Muneer Amanullah

Department of Paediatrics and Child Health

Objective: To evaluate the midterm results of Contegra conduit.
Methods: The retrospective study comprised patient record at Aga Khan University Hospital, Karachi, of conduits implanted between May 2007 and June 2012. Data collection was made from the clinical notes and from serial echocardiograms by a single cardiologist. The last followup echocardiography was done at the time of data collection in June 2012. SPSS 19 was used for statistical analysis.
Results: A total of 18 conduits had been implanted (16-22mm) during the study period. Median age at the time of surgery was 9 years (range: 2.5-16 years). Early mortality was seen …

Oesophageal Duplication Cyst Presenting As Haemoptysis, Noureen Afzal, Syeda Ezz-E-Rukhshan Adil, Ammara Mushtaq, Arshalooz Rahman, Muneer Amanullah

Department of Paediatrics and Child Health

Duplications of the alimentary tract include a variety of cysts, diverticula, and tubular malformations, all believed to have embryological origin. The cysts are most commonly found in children, and the diagnosis is made in infancy in the majority of patients. We report a case of a two-and-a-half year old child, presenting with the history of repeated episodes of haematemesis. Upper GI endoscopy was unremarkable and the chest x-ray showed no pathology. Computed tomography (CT) angiogram revealed soft tissue density lesion in the right chest at the level of T6. Right thoracotomy suggested a cystic mass close to the oesophagus which …

Fak Is A Critical Regulator Of Neuroblastoma Liver Metastasis, Sora Lee, Jingbo Qiao, Pritha Paul, Kathleen L. O'Connor, B. Mark Evers, Dai H. Chung

Surgery Faculty Publications

Neuroblastomas express increased levels of gastrin-releasing peptide receptor (GRP-R). However, the exact molecular mechanisms involved in GRP-R-mediated cell signaling in neuroblastoma growth and metastasis are unknown. Here, we report that focal adhesion kinase (FAK), as a critical downstream target of GRP-R, is an important regulator of neuroblastoma tumorigenicity. We found that FAK expression correlates with GRP-R expression in human neuroblastoma sections and cell lines. GRP-R overexpression in SK-N-SH cells increased FAK, integrin α3 and β1 expressions and cell migration. These cells demonstrated flatter cell morphology with broad lamellae, in which intense FAK expression was localized to the leading edges of …

Emil Theodor Kocher, M.D., And His Nobel Prize (1841-1917)., Zhi Ven Fong, B.S., Ernest L. Rosato, Md, Harish Lavu, Md, Charles J. Yeo, Md, Scott W. Cowan, Md

Department of Surgery Gibbon Society Historical Profiles

Major contributions to the advancement of surgery occurred at the turn of the 20th century. Theodor Billroth was in the midst of revolutionizing abdominal surgery, whereas Louis Pasteur and Joseph Lister were making landmark strides in antisepsis, forever changing the foundations of surgical thinking. Undoubtedly, Theodor Kocher’s (Fig. 1) exposure to these and other giants had a major influence on his career and contributed to his success and ascent as the first, and one of only 10, surgeons ever to be awarded the Nobel Prize in Medicine.

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 …

Venoarterial Extracorporeal Membrane Oxygenation (Ecmo) For Support During Whole Lung Lavage For Pulmonary Alveolar Proteinosis., Hitoshi Hirose, Julie Monteagudo, Nicholas C. Cavarocchi, Boyd Hehn, Naveed Hasan

Department of Surgery Faculty Papers

INTRODUCTION ECMO as support during whole lung lavage (WLL) for pulmonary alveolar proteinosis is reserved for severe cases where oxygenation is inadequate to support the patient using the ventilator alone. While most publications describe a venovenous cannulation with variable results we present a successful case using venoarterial cannulation and discuss the potential benefits of this mode of ECMO support. CASE PRESENTATION We present the case of a 44 year old female with a past medical history of Behcets disease and a BMI of 37 who was diagnosed with pulmonary alveolar proteinosis (PAP) on a lung biopsy after presenting with dyspnea. …

Novel Approach To Monitoring Renal Perfusion With The Use Of Continuous Renal Oximetery In The Setting Of Aortic Dissection, Hitoshi Hirose, Philip Batista, Nicholas C. Cavarocchi

Department of Surgery Faculty Papers

INTRODUCTION: Aortic dissections commonly extend beyond the renal arteries with varying effects ranging from asymptomatic to renal failure. We report a case of aortic dissection with initial renal compromise, which was continuously monitored utilizing direct renal oximetry for evaluation of real-time renal perfusion and function. CASE PRESENTATION: A 65 year-old female with a long history of uncontrolled hypertension presented with acute retrosternal chest pain radiating to the back for 12 hours. She was in stable condition except for a serum creatinine of 1.6mg/dl. Magnetic resonance angiography (MRA) demonstrated a type A dissection extending from the aortic root to the left …

Sternal Pain After Rigid Fixation: A Pilot Study Of Randomization Rigid Vs Conventional Wire Closure., Hitoshi Hirose, Hong Mun Kong, Shigeki Tabata, Kentaro Yamane, Margaret Lusardi, Linda J. Bogar, James Diehl

Department of Surgery Faculty Papers

Objective: Rigid sternal fixation may provide better sternal closure than conventional sternal wire closure. We performed a prospective randomized study to investigate if rigid closure reduces postoperative sternal pain. Methods: Patients undergoing CABG ± valve surgery between July 2011 and January 2012 were prospectively randomized into conventional wire closure (group C) or rigid fixation using sternal plates (group R). Pain scores were determined at 6 AM using a numeric rating scale (0 no pain, 5 moderate pain, 10 worst possible pain). Narcotic pain medication requirement from day 1 to 5 was collected and converted into intravenous morphine equivalent. Results: Among …

Fate Of The Lower Extremity In Patients With Va-Ecmo Via Femoral Cannulation, Hitoshi Hirose, Kathleen Lamb, Neil Moudgill, Paul Dimuzio, Megan Mccullough, Pawel Karbowski, Atul Rao, Nicholas Cavarocchi, Joshua Eisenberg

Department of Surgery Faculty Papers

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Femoral cannulation is associated with limb complications including ischemia, limb loss, arterial infections and wound infections. This study aims to evaluate these complications and management related to successful outcomes. Methods: A retrospective review was conducted in 17 patients requiring VA- ECMO support via femoral cannulation from 1/ 2010 till 4/2012. After cannulation, all patients had near infared spectroscopy (NIRS) monitoring after cannula placement and most had placement of distal arterial perfusion catheters (DPC). At decannulation, all patients had femoral cutdown with closure of arteriotomies …

Percutaneous Gastrostomy (Peg) Tube Placement In Patients With Continuous Flow Left Ventricular Assist Device. (Lvad)., Hitoshi Hirose, Chris Rizzi, Linda Bogar, Jay S. Jenoff, Nicholas Cavarocchi

Department of Surgery Faculty Papers

Percutaneous gastrostomy (PEG) tube placement in patients with continuous flow left ventricular assist device. (LVAD). CHRIS RIZZI, BS, Linda Bogar, MD, Jay Jenoff, MD, Nicholas Cavarocchi, MD, Hitoshi Hirose, MD. Department of Surgery, Thomas Jefferson University, Philadelphia, PA. Introduction: Inadequate nutritional support after LVAD placement is known to increase postoperative infections and to decrease survival. The LVAD patients with complicated postoperative recovery requiring prolonged mechanical ventilation may require long-term tube feedings. Placement of a PEG requires knowledge of the location of the LVAD pocket and driveline to avoid device infection and injury. Methods: Between August 2008 and December 2011, 39 …

Successful Liver Failure Management Using Molecular Adsorbents Recirculating System During Complicated Veno-Arterial Extracorporeal Membrane Oxygenation As A Bridge To A Left Ventricular Assist Device Placement, Hitoshi Hirose, Shigeki Tabata, Nicholas Cavarocchi

Department of Surgery Faculty Papers

Successful liver failure management using molecular adsorbents recirculating system during complicated veno-arterial extracorporeal membrane oxygenation as a bridge to a left ventricular assist device placement. SHIGEKI TABATA, MD, Nicholas Cavarocchi, MD, Hitoshi Hirose, MD. Department of Surgery, Division of Cardiothoracic Surgery Thomas Jefferson University Hospital, Philadelphia, PA Introduction: Extracorporeal membrane oxygenation (ECMO) is a well-established therapy for the patients with cardiogenic shock. We present a patient who developed severe complications while on ECMO. Case presentation: A 49-year-old female presented with severe heart failure and was placed on veno-arterial ECMO for bridge to decision. While on ECMO, the patient developed massive …

Recovery Of End-Organs And Improved Mortality In Adult Patient On Ecmo., Hitoshi Hirose, Joshua Wong, Vei Shaun Siow, Thomas N. Smith, Harrsion Pitcher, Linda Bogar, Nicholas C. Carvarocchi

Department of Surgery Faculty Papers

Title: Recovery of End-Organs and Improved Mortality in Adult Patients on ECMO Joshua K Wong, BS1, Vei Shaun Siow, BS1, Thomas N Smith, BS1, Harrison Pitcher, MD2, Linda Bogar, MD2, Hitoshi Hirose, MD2 and Nicholas C Cavarocchi, MD2. 1Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States, 19107 and 2Division of Cardiothoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States, 19107. Body: With increasing use of ECMO in adults, we seek to objectively measure End-Organ recovery and correlate intensive care mortality scores and complications with patient survival. This is a retrospective review of patients who were placed on …

Efficacy Of Miniaturized Imacor Trans-Esophageal Echocardiografm (Tee) Prove In Mechanical Circulatory Support., Hitoshi Hirose, Christopher Y. Kang, Joshua K. Wong, Harrison T. Pitcher, Caitlyn M. Johnson, Konrad Sarosiek, Linda J Bogar, Nicholas C. Cavarocchi

Department of Surgery Faculty Papers

Application of the miniaturized ImaCor Trans-Esophageal Echocardiogram (TEE) probe in Heart Transplant/Mechanical Cardiac Support Patients In the surgical cardiac care unit (SCCU), therapeutic interventions often need to be done at the bedside, necessitating the need for a rapidly employable diagnostic tool for the cardiac intensivist. We report the clinical utility of the miniature ImaCor TEE-probe in guiding management of post heart transplant (H-Txp) and mechanical cardiac support patients (MCS) and describe the economic benefit of such a device. This is an IRB approved retrospective review of MCS/H-Txp patients who had ImaCor TEE monitoring in the SCCU of our institution in …

An Old Problem With A New Therapy: Gi Bleeding In Vad Patients And Deep Bowel Enteroscopy (Double Balloon. Spiral Enteroscopy)., Hitoshi Hirose, Konrad Sarosiek, Linda Bogar, Pitcher Harrison, Barbara Ebert, Nicholas Cavarocchi

Department of Surgery Faculty Papers

An old problem with a new therapy: GI Bleeding in VAD patients and deep bowel enteroscopy (Spiral and Double Balloon Enteroscopy) Purpose: Evidence suggests that patients treated with non-pulsatile ventricular assist devices (VAD) are at an increased risk for gastrointestinal bleeding (GIB) beyond what is expected from routine anticoagulation. Diagnostic and treatment algorithms are currently undefined. We reviewed our experience of GIB in VAD patients and propose a new algorithm utilizing deep bowel enteroscopy (DBE) aimed to speed diagnosis and limit transfusions. (471) Methods & Procedures From 2004 to 2011, we studied 62 patients who received a non-pulsatile VAD at …

Quantitative, Spectrally-Resolved Intraoperative Fluorescence Imaging, Pablo A. Valdés, Frederic Leblond, Valerie L. Jacobs, Brian C. Wilson, Keith D. Paulsen, David W. Roberts

Dartmouth Scholarship

Intraoperative visual fluorescence imaging (vFI) has emerged as a promising aid to surgical guidance, but does not fully exploit the potential of the fluorescent agents that are currently available. Here, we introduce a quantitative fluorescence imaging (qFI) approach that converts spectrally-resolved data into images of absolute fluorophore concentration pixel-by-pixel across the surgical field of view (FOV). The resulting estimates are linear, accurate, and precise relative to true values, and spectral decomposition of multiple fluorophores is also achieved. Experiments with protoporphyrin IX in a glioma rodent model demonstrate in vivo quantitative and spectrally-resolved fluorescence imaging of infiltrating tumor margins for the …

T-Cell Activation Is Enhanced By Targeting Il-10 Cytokine Production In Toll-Like Receptor-Stimulated Macrophages, Ryan Walk, Steven Elliott, Felix C. Blanco, Jason A. Snyder, Ashley M. Jacobi, Scott Rose, Mark Behlke, Aliasger Salem, Stanislav Vukmanovic, Anthony D. Sandler

Surgery Faculty Publications

Toll-like receptor (TLR) agonists represent potentially useful cancer vaccine adjuvants in their ability to stimulate antigen-presenting cells (APCs) and subsequently amplify the cytotoxic T-cell response. The purpose of this study was to characterize APC responses to TLR activation and to determine the subsequent effect on lymphocyte activation. We exposed murine primary bone marrow-derived macrophages to increasing concentrations of agonists to TLRs 2, 3, 4, and 9. This resulted in a dose-dependent increase in production of not only tumor necrosis factor–alpha (TNF-α), a surrogate marker of the proinflammatory response, but also interleukin 10 (IL-10), a well-described inhibitory cytokine. Importantly, IL-10 secretion …

Foleys Protection Caps: Inexpensive Alternative In Ilizarov Fixation, K Abbas, H Rashid

Section of General Surgery

No abstract provided.

John Y. Templeton Iii: Pioneer Of Modern Cardiothoracic Surgery., Jing Li, B.S., Herbert E. Cohn, Md, Charles J. Yeo, Md, Scott W. Cowan, Md

Department of Surgery Gibbon Society Historical Profiles

John Young Templeton III was born in 1917 in Portsmouth, Virginia, and graduated from Jefferson Medical College in 1941. He completed his residency training under Dr. John H. Gibbon, Jr., and was the first resident who worked on Gibbon's heart-lung machine. After his training, he remained at Jefferson as an American Cancer Society fellow and Damon Runyon fellow and went on to become the fourth Samuel D. Gross Professor and Chair of the Department of Surgery in 1967. Dr. Templeton was the recipient of numerous grants and published over 80 papers in the field of cardiothoracic surgery. As a teacher …