Taylor M. Coe

Small bowel volvulus in the adult populace of the United States: results from a population-based study

BACKGROUND Small bowel volvulus is a rare entity in Western adults. Greater insight into epidemiology and outcomes may be gained from a national database inquiry. METHODS The Nationwide Inpatient Sample (1998 to 2010), a 20% stratified sample of United States hospitals, was retrospectively reviewed for small bowel volvulus cases (International Classification of Diseases, 9th Edition [ICD-9] code 560.2 excluding gastric/colonic procedures) in patients greater than or equal to 18 years old. RESULTS There were 2,065,599 hospitalizations for bowel obstruction (ICD-9 560.x). Of those, there were 20,680 (1.00%) small bowel volvulus cases; 169 were attributable to intestinal malrotation. Most cases presented emergently (89.24%) and operative management was employed more frequently than nonoperative (65.21% vs 34.79%, P < .0001). Predictors of mortality included age greater than 50 years, Charlson comorbidity index greater than or equal to 1, emergent admission, peritonitis, acute vascular insufficiency, coagulopathy, and nonoperative management (P < .0001). CONCLUSION As the first population-based epidemiological study of small bowel volvulus, our findings provide a robust representation of this rare cause of small bowel obstruction in American adults.

Surgical Management of Adolescents and Young Adults With Gastrointestinal Stromal Tumors: A US Population-Based Analysis

Importance There is a dearth of population-based evidence regarding outcomes of the adolescent and young adult (AYA) population with gastrointestinal stromal tumors (GISTs). Objectives To describe a large cohort of AYA patients with GISTs and investigate the effect of surgery on GIST-specific survival (GSS) and overall survival (OS). Design, Setting, and Participants This retrospective cohort study of 392 AYA patients and 5373 older adult (OA) patients in the Surveillance, Epidemiology, and End Results (SEER) database with GISTs histologically diagnosed from January 1, 2001, through December 31, 2013, with follow-up through December 31, 2015, compared the baseline characteristics of AYA (13-39 years old) and OA (≥40 years old) patients and among AYA patients stratified by operative management. Kaplan-Meier estimates were used for OS analyses. Cumulative incidence functions were used for GSS analysis. The effect of surgery on survival was evaluated with a multivariable Fine-Gray regression model. Exposure Tumor resection. Main Outcomes and Measures GIST-specific survival and OS. Results This study included 392 AYA and 5373 OA patients diagnosed with GISTs (207 [52.8%] male AYA patients, 2767 [51.5%] male OA patients, 277 [70.7%] white AYA patients, and 3661 [68.1%] white OA patients). Compared with the OA patients, more AYA patients had small-intestine GISTs (139 [35.5%] vs 1465 [27.3%], P = .008) and were managed operatively (332 [84.7%] vs 4212 [78.4%], P = .003). Multivariable analysis of AYA patients found that nonoperative management was associated with a more than 2-fold increased risk of death from GISTs (subdistribution hazard ratio, 2.27; 95% CI, 1.21-2.25; P = .01). On subset analysis of 349 AYA patients with tumors of the stomach and small intestine, small-intestine location was associated with improved survival (OS: 91.1% vs 77.2%, P = .01; GSS: 91.8% vs 78.0%, P = .008). On subset analysis of 91 AYA patients with metastatic disease, operative management was associated with improved survival (OS: 69.5% vs 53.7%, P = .04; GSS: 71.5% vs 56.7%, P = .03). Conclusions and Relevance This study found that AYA patients are more likely to undergo surgical management than OA patients. Operative management is associated with improved OS and GSS in AYA patients, including those with metastatic disease.

Lipofibromatosis-like neural tumor: Case report of a unique infantile presentation

A 14-month-old boy presented with a slow-growing, asymptomatic back plaque, which was biopsied and found to have S100 positivity, sparse CD34 staining, and no significant mitotic activity, nuclear pleomorphism, or necrosis; genetic workup found LMNA-NTRK1 gene fusion, overall consistent with lipofibromatosis-like neural tumor (LPF-NT). LPF-NT is rare, with 14 cases previously reported, and our patient is the first report of this diagnosis in infancy. This case report and literature review includes comparison of similar diagnoses including lipofibromatosis, low-grade malignant peripheral nerve sheath tumor, infantile fibrosarcoma, and dermatofibrosarcoma protuberans and serves to aid detection of LPF-NT presenting in pediatric patients by highlighting similarities and differences that should prompt consideration. LPF-NT shows locally aggressive behavior only and should not be confused with conditions that have potential for distant spread. However, case reports of metastasizing LMNA-NTRK1 tumors draw into question whether growths with this gene fusion exist on a spectrum of disease severity. Our patient was treated with wide local excision and has developed no complications or evidence of recurrence with 6 months of follow-up time.

An inexpensive yet realistic model for teaching vasectomy

Purpose Teaching the no-scalpel vasectomy is important, since vasectomy is a safe, simple, and cost-effective method of contraception. This minimally invasive vasectomy technique involves delivering the vas through the skin with specialized tools. This technique is associated with fewer complications than the traditional incisional vasectomy (1). One of the most challenging steps is the delivery of the vas through a small puncture in the scrotal skin, and there is a need for a realistic and inexpensive scrotal model for beginning learners to practice this step. Materials and Methods After careful observation using several scrotal models while teaching residents and senior trainees, we developed a simplified scrotal model that uses only three components–bicycle inner tube, latex tubing, and a Penrose drain. Results This model is remarkably realistic and allows learners to practice a challenging step in the no-scalpel vasectomy. The low cost and simple construction of the model allows wide dissemination of training in this important technique. Conclusions We propose a simple, inexpensive model that will enable learners to master the hand movements involved in delivering the vas through the skin while mitigating the risks of learning on patients.

Epidemiology of GIST

Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that are found throughout the gastrointestinal tract. They are molecularly characterized by gain-of-function mutations in oncogenes, including c-KIT and PDGFRα. They are believed to arise from the interstitial cells of Cajal within the myenteric plexus of the gut. Many studies have characterized the incidence of GIST in the United States, Europe, and Asia. The annual incidence reported in the literature varies by region: 3.2–6.8 cases per million persons in the United States; 2.1–14.5 cases per million persons in Europe; and 11.3–19.7 cases per million persons in Asia. However, many of these earlier studies were confounded by additional histologies confused with GIST, including leiomyoma, leiomyosarcoma, or neurofibroma. Across multiple studies, it has been shown that GIST is more common in older patients, males, Blacks, and Asian/Pacific Islanders. The average age at diagnosis ranges from 62 to 75, with peak incidence in the 8th decade of life. In regard to tumor-related characteristics, the stomach is consistently the most common tumor location followed by the small intestine. Finally, risk factors associated with death include increased age at diagnosis, male sex, Black race, and the presence of regional and/or metastatic disease. Taken together, our understanding of the patient- and disease-related characteristics of GIST has evolved over the last two decades. As further insights are gained into the biology of this disease, we continue to translate these into a better understanding of the epidemiology of GIST.

Expanding our Understanding of Patient Outcomes: The Unique role of Health Services Research in the Continuing Evolution of Surgical Science

As modern medicine began in the 20th Century, most of the early research efforts were focused on developing and refining treatment modalities. This focus on therapeutic efficacy was rightly so, as a profession cannot begin to exist and flourish until an armamentarium of tools is available for its practitioners. The randomized control trial (RCT) emerged during this time as the gold standard for clinical research given its unparalleled strength in isolating therapeutic effects and confirming the efficacy of new treatment modalities.

Are Risks of Adverse Outcomes Following Outpatient Cosmetic Procedures Additive When Procedures Are Combined

Methods: Retrospective longitudinal analysis was performed of the 2005-2010 California Office of Statewide Health Planning and Development (OSHPD) Ambulatory Surgery Database, which contains data for ambulatory surgery centers licensed by the California Department of Public Health. Patients were included if they had undergone an abdominoplasty or any other procedure that was identified as frequently performed concurrently with abdominoplasty liposuction, breast procedures, face procedures, thighlift/brachioplasty, and hernia repair. Patients’ subsequent in-patient admissions and emergency department visits were identified from the respective OSHPD databases, capturing all admissions to non-military hospitals in the state. Outcomes analyzed were the one-year venous thromboembolism (VTE) rate, 30-day readmission rate, 30-day emergency department visit rate, and 30-day mortality. All outcomes were analyzed for patients undergoing an isolated procedure and two concurrent procedures.