Bile Leak following Laparoscopic Cholecystectomy due to Perforated Duodenal Ulcer in Patient with Roux-en-Y Gastric Bypass.

Perforated ulcers of the excluded stomach or duodenum are exceedingly rare in patients who have undergone Roux-en-Y gastric bypass surgery. The diagnosis of perforated ulcer after Roux-en-Y gastric bypass remains challenging as there is often absence of free air or contrast extravasation from the biliopancreatic limb. We present a patient with signs and symptoms of acute cholecystitis. Laparoscopic cholecystectomy was complicated by postoperative bile leak. EDGE procedure was performed to access the remnant stomach and endoscopic evaluation revealed a perforated ulcer in the posterior duodenal bulb. Although unusual, in patients with bariatric surgery and upper abdominal pain, differential diagnosis including perforated ulcer of the biliopancreatic limb must be considered and early surgical exploration is essential.

The use of percutaneous-endoscopic rendezvous stenting in a patient with bile duct injury after cholecystectomy-and a unique complication requiring secondary endoscopic intervention.

Bile duct injury (BDI) is a potentially devastating complication after cholecystectomy. Familiarity with the diagnosis and multidisciplinary treatment options is imperative. This report highlights the utility of the rendezvous stenting procedure in a high-risk patient and describes a rare complication involving stent misplacement through the surgical drain. This is a 96-year-old female patient who suffered a Strasburg Class D injury during cholecystectomy, repaired over a T-tube. The T-tube dislodged postoperatively. Endoscopic and transhepatic stenting attempts were unsuccessful. Ultimately, a rendezvous approach allowed successful deployment of a covered metal stent. The stent was inadvertently deployed through a side fenestration of a surgical drain and was explanted upon drain removal. Repeat endoscopic stent placement was successful. The patient recovered without further complication. Surgical drains near the BDI can become sources of unexpected complications. A higher index of suspicion and careful interpretation of procedural imaging studies may prevent this complication.

Case of second primary breast cancer in ectopic breast tissue and review of the literature.

Accessory breast tissue (ABT) is found in approximately 2%-6% of the female population and are subject to most of the physiological and pathological changes that occur in pectoral breast. Primary breast cancer occurring in ABT is a rare occurrence and a second primary breast cancer occurring in an accessory breast has never been reported. We report the case of a 60-year-old woman with a history of mastectomy for left breast cancer 5 years prior to presentation, who presented with an enlarging right axilla mass found to be a second primary breast cancer in an accessory tissue on biopsy. Many physicians are unfamiliar with the clinical presentation of accessory breast cancer due to the rarity of the condition and this ultimately results in delayed diagnosis and advanced disease at presentation. It is therefore prudent that physicians have a high index of suspicion when patients present with axillary masses.

Limb Salvage Resection of Massive Dedifferentiated Thigh Liposarcoma in a Patient Lost to Follow-Up.

Dedifferentiated liposarcoma (DDL) is a rare soft tissue tumor that represents a non-lipogenic progression of well-differentiated liposarcoma (WDL). Unlike WDL, DDL has the propensity for metastasis and is associated with an increased incidence of local recurrence. For DDL of the extremities that is resectable with acceptable functional outcomes, treatment includes primary surgical resection with negative margins. Although rare due to advances in reconstructive techniques, amputation for DDL of the extremities should be considered in which appropriate tumor resection cannot be performed without adequate preservation of limb function. We present the clinical progression of a patient with a large DDL of the right thigh who was initially lost to follow-up, but ultimately underwent delayed definitive therapy with the intent for limb salvage. This case illustrates the importance of assessing neurovascular, osseous, and soft tissue involvement to properly predict and preserve limb function while achieving adequate tumor resection.

Fournier's Gangrene in the Setting of Underlying Carcinoma: A Case Report and Review of the Literature.

Most case series of Fournier's gangrene (FG) do not list malignancy as a cause; however, isolated cases with underlying malignancy of the soft tissue, genitourinary, and gastrointestinal systems have been described. After a review of recently published literature, 20 case reports and 15 case series or review articles included relevant information and were included in this literature review. Malignancy is overlooked in 10% (2/20) of patients, resulting in a delayed diagnosis and initiation of cancer treatment. All patients with FG should have a thorough cancer history, digital rectal examination, appropriate local and systemic imaging, as well as tissue biopsies, to reduce the likelihood of a missed cancer diagnosis. Delay in management of the local malignancy may lead to persistence or recurrence of the infection and significantly worsens overall outcome and survival.

Is It Safe to Perform Lung Surgery During the Coronavirus Pandemic?

BACKGROUND:  Coronavirus disease (COVID-19) patients are rapidly growing in our community. Patients with compromised lungs and older age are supposedly at high risk of poor outcomes with COVID-19. We aimed to evaluate the COVID-19 impact on lung surgery during this pandemic at our hospital. METHODOLOGY: This is a retrospective study of all lung surgery patients at our hospital in Boca Raton over three months (February to April 2020). All patients who remained for at least one-day inpatient post-lung surgery were assessed to see if they had an increased incidence of coronavirus infection during the hospital stay or at the follow-up office visit. RESULTS: A total of 44 patients underwent thoracic surgery. It was found that there was no incidence of coronavirus infection in these patients. CONCLUSION: With adequate precautions, older patients can undergo lung surgery during this pandemic. There was no incidence of COVID-19 found among the patients during the hospital stay or at the first follow-up in the office. Also, the postoperative course was not adversely affected.

Negative Pressure Wound Therapy Can Prevent Surgical Site Infections Following Sternal and Rib Fixation in Trauma Patients: Experience From a Single-Institution Cohort Study.

The management of patients with traumatic injuries can be a challenge. Many require surgical intervention, are at an increased risk of surgical site infections (SSIs), and have an associated increase in hospital length of stay and cost. Closed-incision negative pressure therapy (ciNPT) has shown benefits in the management of certain surgical sites by preventing infection and improving wound healing. In the setting of chest wall reconstruction after traumatic sternal and/or rib fractures, no study so far has examined the efficacy of this treatment. We report a single-center retrospective cohort study, examining outcomes using ciNPT following rib and sternal fixation in trauma patients. Data on 71 patients who suffered from rib and/or sternal fractures, requiring surgical intervention, were collected over a time period of three years, from December 2016 to December 2019. The patient population was 66% male (47/71), had a mean age of 63.3 years (range 23-90 years old), and suffered from injuries related to motor vehicle or motorcycle accidents (45/71, 63%). Among the patients treated with ciNPT, none developed signs of SSIs during their initial hospitalization or within two months post-discharge follow-up. Negative pressure therapy is an effective wound care management system for preventing infections in closed-incision sites following chest wall reconstruction.

Rare Case of a Transverse Colon Schwannoma.

Schwannomas are tumors comprised of schwann cells of the peripheral nervous system and infrequently present in the gastrointestinal tract. Transverse colon schwannomas are an even more rare subtype of gastrointestinal schwannomas. This study presents the case of a transverse colon schwannoma, in addition to presenting a literature review.

Transdiaphragmatic-pericardial Hernia: Case Report of an Unusual Condition Managed by Utilization of a Robotic Surgical System.

Transdiaphragmatic hernia via the central tendon in the pericardium is a rare entity. Most often, these hernias are acquired and related to the iatrogenic creation of a transdiaphragmatic-pericardial defect. We would like to present a case of a 62-year-old male who presented with acute chest pain and was diagnosed to have a transdiaphragmatic-pericardial hernia on computed tomography. He has a history of cardiac intervention via an abdominal approach 12 years earlier. A segment of jejunum was found strangulated in the defect. We used DaVinci Xi® (Intuitive Surgical, Sunnyvale, CA) robot and were able to successfully reduce the hernia, repair the defect, and resect a short segment of jejunum which was non-viable. The utilization of a minimally invasive approach may be feasible, and the use of a robotic surgical system may enhance the surgeon's ability to repair the defect.

A Case Report of a Ventral Hernia Containing a Liver Cyst in a Patient with Autosomal Dominant Polycystic Kidney Disease.

Autosomal dominant polycystic kidney disease (ADPKD) is the most commonly inherited renal disorder and the fourth most common cause of end-stage renal disease. ADPKD is a systemic disease with multiple extrarenal manifestations, including cystic involvement of other organs, such as the liver and pancreas, and connective tissue abnormalities. The prevalence of hernias is higher in patients with ADPKD. It has been hypothesized that these hernias are the result of abnormal extracellular matrix production and/or increased intra-abdominal pressure from the cyst burden. We present a case of a 56-year-old female with polycystic kidney disease who was admitted for an incarcerated ventral hernia. The patient presented with obstructive symptoms concerning for bowel impingement. The patient underwent operative management, and during the procedure, an incarcerated liver cyst was identified in the hernia sac. This was successfully reduced, and the hernia was repaired with mesh.

The Effectiveness of Laparoscopic-assisted Percutaneous Endoscopic Gastrostomy in Patients with Unfavorable Anatomy: A Single-center Retrospective Cohort Study.

Percutaneous endoscopic gastrostomy (PEG) is an easy means to provide enteral access in patients unable to maintain adequate nutrition via the oral route. In patients with morbid obesity, altered intra-abdominal anatomy due to prior abdominal surgery, the interposition of the colon or other factors precluding endoscopy, feeding tube placement by laparoscopic means (LAPEG) can provide a potentially safe alternative. The objective of this study was to examine the efficacy and outcomes of laparoscopic-assisted placement of PEG in adult patients. This is a retrospective cohort analysis of adult patients, who underwent PEG and/or laparoscopic-assisted percutaneous endoscopic gastrostomy placement (LAPEG) by two surgeons at a single institution. A total of 36 patients underwent PEG and/or LAPEG. No significant differences were found in the total and postoperative length of stay and mortality. There were no procedure-related complications in the LAPEG group versus two in the PEG group (8.7%), but this did not reach statistical significance. LAPEG was 100% successful in gaining enteral feeding access in patients that had failed PEG. The most common reason for PEG placement failure was colonic interposition (39%), followed by intra-abdominal adhesions and gastric displacement by hiatal hernia (each 23%). 38.5% of LAPG procedures could be done via 5-mm single port access, 38.5% required two-port and 23% required three-port access. In conclusion, LAPEG is a feasible minimally invasive alternative to gain enteral feeding access in patients that have failed PEG that does not increase the length of stay, morbidity or mortality.

In by helicopter out by cab: the financial cost of aeromedical overtriage of trauma patients.

BACKGROUND: Helicopter transport of injured patients is controversial and costly. This study aims to show that a complex trauma algorithm leads to significant aeromedical overtriage at substantial cost. Our secondary outcomes were to compare adjusted mortality and outcomes between air and ground transport and determine predictors of overtriage. MATERIALS AND METHODS: A 6-y retrospective analysis was conducted of all trauma activations at a Level I center. Patients were dichotomized by transportation method as well as trauma activation criteria. Overtriage was defined as those who were discharged from the emergency department, medically admitted without injuries, or admitted to observation status only. Overtriage and associated charges were calculated for each patient cohort, and multivariate regression models were created to derive adjusted mortality rates and predictors of overtriage. RESULTS: A total of 4218 patients were treated with 28% arriving by helicopter. Overtriage increased significantly from 51% to 77% with lower tier activation criteria (P < 0.001). Median charges for air-evacuated patients was $10,478 (versus $1008 ground). Eliminating overtriage of air patients would result in a cost savings of $1,316,036 annually. Adjusted mortality between air and ground transport was not significantly different (8.5% versus 10.9%, P = 0.548). Predictors of overtriage included decreasing age, Injury Severity Score, Head Abbreviated Injury Score, nonoperative treatment, and lower tier activation criteria. CONCLUSIONS: Significant overtriage (52%) and unnecessary air evacuation of minimally injured patients occurs at great financial cost. Revision of trauma activation protocols may result in more judicious air transport use and significant reductions in health care costs.

Management of hemorrhagic shock when blood is not an option.

OBJECTIVE: To describe an alternative approach to management of severe life- threatening hemorrhagic shock and the outcome when blood was not a treatment option. DESIGN: Case Report of the use of a Hemoglobin Based Oxygen Carrier (HBOC-201)when control of hemorrhage and intravenous crystalloids were unsuccessful in reversal of hemorrhagic shock and progressive ischemia. SETTING: Trauma Center. PATIENTS: Jehovah's Witness. OUTCOME: Hospital discharge and 6 month follow-up uneventful.

Serum lipopolysaccharide-binding protein concentrations in trauma victims.

BACKGROUND: In low concentrations, lipopolysaccharide-binding protein (LBP), an acute-phase protein recognizing lipopolysaccharide (LPS), catalyzes its transfer to the cellular receptor consisting of CD14 and Toll-like receptor-4. Previous studies have documented increased serum LBP concentrations in patients with sepsis, systemic inflammatory response syndrome (SIRS), or acute pancreatitis and after cardiopulmonary bypass. No prior studies have examined LBP expression in trauma victims. We hypothesized that admission LBP plasma concentrations are predictive of outcome (mortality) in trauma. This study assessed time-dependent changes in serum LBP concentrations in trauma patients soon after injury. METHODS: A prospective, single-institution, observational cohort study of 121 adult trauma patients (age > or =17 years) with moderate to severe injury who required hospitalization. The trauma patients were male in 79.6% of the cases and had a mean age of 43.0 +/- 20.6 years. The mean injury severity score (ISS) was 23 +/- 12, and the crystalloid resuscitation volume given in the first 24 h averaged 6,640 +/- 3,729 mL. Informed consent was obtained on admission, and blood samples were drawn on admission and at 24 h postadmission. Prospective data were collected for daily SIRS score, multiple organ dysfunction score (MODS), and sequential organ failure assessment (SOFA) score, complications, and outcomes. Plasma concentrations of LBP were measured by enzyme-linked immunosorbent assay. RESULTS: Sixty patients (48.8% of the study cohort) required emergency surgical intervention and sustained a substantial intraoperative blood loss (mean 1,404 +/- 2,757 mL). The hospital mortality rate was 16.3% (20 patients). The mean intensive care unit stay was 8.9 +/- 16.4 days, and the hospital stay was 14.8 +/- 19.6 days. The patients had a significantly higher serum concentrations of LBP on admission (mean 28.0 +/- 25.3 mg/L; range 2-100 mg/L) than did control subjects (mean 6.2 +/- 2.1 mg/L; range 1.3-12.8 mg/L; p < 0.01), similar to the plasma concentrations previously reported in septic patients. A significant increase in LBP concentration was noted at 24 h (mean 72.3 +/- 45.7 mg/L; range 8-210 mg/L; p < 0.05). The admission LBP concentration was significantly greater in nonsurvivors than in survivors. However, after controlling for age and ISS, the admission LBP concentration did not predict death.