Significance of Scapular Fracture Existence in Blunt Chest Trauma: A Retrospective Cohort Study.

Background: Scapular fracture is a rare encounter in blunt trauma patients. The scapula is surrounded by strong groups of muscles offering good protection for the bone. Therefore, a high-energy trauma is needed to cause a scapular fracture. We aim to study scapular fractures and their relation to injury severity and mortality in blunt chest trauma (BCT) patients. Methods: We retrospectively collected data from all patients with BCT who were admitted to our hospital from December 2014 through January 2017. The injury details of all BCT patients were retrieved from the trauma registry of the hospital and were supplemented by patients' electronic files for missing information. Collected data included demography, mechanism of injury, vital signs, Glasgow Coma Score (GCS) on admission, injured body regions, management, Injury Severity Score (ISS), New Injury Severity Score (NISS), length of hospital stay (LOS), and mortality. Results: During the study period, 669 patients had BCT. Scapular fracture was present in 29 (4.3%) of the BCT patients. The scapular fracture was missed by chest X-ray in 35.7% of the patients; however, it was accurately diagnosed by computed tomography (CT) scan of the chest. Neck injury was significantly higher in patients with scapular fracture compared with patients without fracture (p < 0.001). ISS and NISS were significantly higher in patients with scapular fractures compared to other patients without fractures (p=0.04 and p=0.003 Mann-Whitney U test, respectively). Two patients with scapular fractures died due to severe associated injuries (the overall mortality was 9.6%). Conclusions: Scapular fracture in BCT patients indicates a high-energy type of trauma. Compared to a chest X-ray, CT scan was more accurate for the diagnosis of scapular fracture. Associated injuries are the main cause of trauma-related mortality rather than the direct effect of the fractured scapula. Particular attention and meticulous evaluation should be paid to head and neck injuries to avoid missing injuries.

Management of Fourniers gangrene secondary to perineal invasion by rectal cancer.

INTRODUCTION AND IMPORTANCE: Fournier's gangrene is a known disease process resulting in a severe necrotizing soft tissue infection involving the perineum and scrotum. Although most cases are known to be associated with diabetes (Go et al., 2010 [1]), it is rare to develop this extensive infection secondary to tumor invasion from the rectum. Treatment typically requires several debridements until infection is fully controlled. CASE PRESENTATION: A 65 year old man with a history of locally invasive and unresectable rectal cancer presents to our emergency department with severe perineal and scrotal pain and was found to be in septic shock. He had previously undergone a diverting colostomy as well as radiation to the pelvis. He underwent several surgical debridements until the infection was controlled. He then required procedures to close the large defects created until complete wound healing was achieved within 3 months of presentation. CLINICAL DISCUSSION: This condition is associated with a high morbidity and mortality, and its management can be split in to two stages. The early phase includes resuscitation, initial debridements and likely several sequential debridements as well as fecal diversion. The late phase then involves the healing process with reconstruction efforts. A multi-disciplinary team is required for appropriate management under the direction of the general surgeon, which also include urologists, plastic surgeons and wound care nurses. CONCLUSION: Fournier's gangrene secondary to tumor invasion should be recognized as a potential cause other than the typical culprits. Resuscitation, antibiotics, debridements and a team approach is needed to recover from such a debilitating disease.

Terminal ileostomy and on-table enteroscopy-A case report describing a novel approach for retrieval of foreign bodies in the difficult abdomen.

INTRODUCTION: With any abdominal surgery in a difficult abdomen, the procedure is filled with potential hazards. In addition to a prolonged operative time, there is a risk of enterotomy or damage to blood vessels and ureters. An irradiated pelvis increases this risk and may cause additional morbidity such as delayed healing. An impacted foreign body can also be a challenging problem to deal with alone but when combined with a difficult abdomen can make the problem impossible. PRESENTATION OF CASE: A 67 year-old male presented with a small bowel obstruction secondary to a foreign body impacted in the distal. The patient had a history of prostate cancer with radiation to the pelvis and thereafter developed perforated diverticulitis, requiring end colostomy. Later he underwent a colostomy take-down but developed wound infection and dehiscence resulting in an incisional hernia which was repaired. The patient failed conservative management and operative intervention was undertaken. Due to the extensive scarring of his midline abdomen, a right sided transverse incision was used. An enterotomy was made in the terminal ileum allowing the endoscope to advance to the foreign body to be retrieved with a snare. The foreign body was found to be a 3.5cm piece of bone. Post-operative course was unremarkable. DISCUSSION: Foreign body ingestion is a rare cause of small bowel obstruction, and exploration and retrieval is recommended if the obstruction does not resolve or if the bowels perforate. The method of retrieval depends on the site of the foreign body. Fortunately, in the small bowel, the terminal ileum is the narrowest part and most likely the site of impaction. Operative retrieval is easier if there are no prior abdominal interventions. An irradiated pelvis or abdomen, multiple prior procedures and a frozen abdomen warrant an alternative approach. As it can be difficult or impossible to access the ileum using a colonoscope transanally, a limited right-sided transverse incision can be employed allowing immediate access to the cecum and terminal ileum through which endoscopic retrieval could be performed. A review of the literature to date did not yield any other descriptions of this approach for foreign body retrieval, however, an appendostomy and endoscopy to rule out malignancy in patients with right sided diverticulitis has been documented. CONCLUSION: Consideration should be given to foreign body retrieval through an appendostomy or ileostomy if a midline laparotomy is considered too high risk in the setting of pelvic irradiation and multiple prior abdominal surgeries.

Bariatric Surgery as a Bridge to Renal Transplantation in Patients with End-Stage Renal Disease.

BACKGROUND: Obesity is a relative contraindication to organ transplantation. Preliminary reports suggest that bariatric surgery may be used as a bridge to transplantation in patients who are not eligible for transplantation because of morbid obesity. SETTING: The Bariatric Center at Tampa General Hospital, University of South Florida, Tampa, Florida. METHODS: We reviewed the outcomes of 16 consecutive patients on hemodialysis for end-stage renal disease (ESRD) who underwent bariatric surgery from 1998 to 2016. Demographics, comorbidities, weight loss, as well as transplant status were reported. Data is mean ± SD. RESULTS: Six men and ten women aged 43-66 years (median = 54 years) underwent laparoscopic Roux-en-Y gastric bypass (LRYGB, n = 12), laparoscopic adjustable gastric banding (LAGB, n = 3), or laparoscopic sleeve gastrectomy (LSG, n = 1). Preoperative BMI was 48 ± 8 kg/m2. Follow-up to date was 1-10 years (median = 2.8 years); postoperative BMI was 31 ± 7 kg/m2; %EBWL was 62 ± 24. Four patients underwent renal transplantation (25%) between 2.5-5 years after bariatric surgery. Five patients are currently listed for transplantation. Five patients were not listed for transplantation due to persistent comorbidities; two of these patients died as a consequence of their comorbidities (12.5%) more than 1 year after bariatric surgery. Two patients were lost to follow-up (12.5%). CONCLUSION: Bariatric surgery is effective in patients with ESRD and improves access to renal transplantation. Bariatric surgery offers a safe approach to weight loss and improvement in comorbidities in the majority of patients. Referrals of transplant candidates with obesity for bariatric surgery should be considered early in the course of ESRD.