Suprapubic catheter placement through ileal mesentery causes mechanical small bowel obstruction six years later in a female patient with turners syndrome.

Percutaneous suprapubic cystostomy (SPC) is a procedure performed to manage urinary retention when urethral catheterization is contraindicated or to improve the quality of life in cases such as neurogenic bladder. Although a simple procedure, it is associated with serious complications, increasing the morbidity and mortality. This case study demonstrates a delayed presentation of small bowel obstruction caused by a suprapubic catheter traversing through the ileal mesentery in a patient with no prior bowel surgeries. Few cases report this complication and this is possibly the first case to be reported six years after SPC placement.

Using cognitive task analysis to identify critical decisions in the laparoscopic environment.

OBJECTIVE: The aim of this study was to identify the critical decisions surgeons need to make regarding laparoscopic surgery, the information these decisions are based on, the strategies employed by surgeons to reach their objectives, and the difficulties experienced by novices. BACKGROUND: Laparoscopic training focuses on the development of technical skills. However, successful surgical outcomes are also dependent on appropriate decisions made during surgery, which are influenced by critical cues and the use of appropriate strategies. Novices might not be as adept at cue detection and strategy use. METHOD: Participants were eight attending surgeons. The authors employed task-analytic techniques to identify critical decisions inherent in laparoscopy and the cues, strategies, and novice traps associated with these decisions. RESULTS: The authors used decision requirements tables to organize the data into the key decisions made during the preoperative, operative, and postoperative phases as well as the cues, strategies, and novice traps associated with these decisions. Key decisions identified for the preoperative phase included but were not limited to the decision of performing a laparoscopic versus open surgery, necessity to review the literature, practicing the procedure, and trocar placement. Some key decisions identified for the operative phase included converting to open surgery, performing angiograms, cutting tissue or organs, and reevaluation of the approach. Only one key decision was identified for the postoperative phrase: whether the surgeon's technique needs to be evaluated and revised. CONCLUSION: The laparoscopic environment requires complex decision making, and novices are prone to errors in their decisions. APPLICATION: The information elicited in this study is applicable to laparoscopic training.

Prognosis of metastatic carcinoma of the lung in the bevacizumab era: comparison between the major histologic types of lung cancer.

BACKGROUND: In October 2006, bevacizumab was approved for treatment for patients with metastatic non-small-cell lung cancer other than squamous carcinoma. Our hypothesis was that the change in survival after approval of bevacizumab for metastatic adenocarcinoma would show differences from that of small-cell carcinoma and squamous carcinoma. METHODS: Data was obtained from the National Cancer Institute Surveillance Epidemiology and End Results (SEER) registry for patients with lung cancer diagnosed between January 2004 and November 2007. In addition to known characteristics predicting survival differences (histotype, age, gender, and race) we compared 1-year survival experience in those diagnosed before (January 2004-September 2006) and after (October 2006-November 2007) introduction of bevacizumab. RESULTS: Of 24,575 patients meeting criteria, 16,081 (65.4%) died within 1 y. Adjusted for age, gender, and race, patients with squamous carcinoma showed a 13% decline (95% CI 7%-20%) in survival times. By contrast, the 1% increment for adenocarcinoma and the 1% decrement for small cell carcinoma might well have been due to chance (P > 0.05 for each analysis). CONCLUSIONS: Life expectancy for metastatic adenocarcinoma (for which bevacizumab is approved) and metastatic small-cell carcinoma (bevacizumab not approved) did not change statistically. On the other hand, life expectancy for patients with metastatic squamous carcinoma (bevacizumab not approved) of the lung has declined since the approval of bevacizumab. This likely reflects increased classification of tumors previously diagnosed as poorly differentiated non-small-cell carcinoma as poorly differentiated squamous carcinoma. Hence, life expectancy of metastatic adeno, squamous, and small-cell-lung cancer has not improved after introduction of bevacizumab.

Nottingham grades of lobular carcinoma lack the prognostic implications they bear for ductal carcinoma.

BACKGROUND: Invasive lobular cancer (L) differs clinically and morphologically from invasive ductal cancer (D); differences notwithstanding, Nottingham grades are provided in both. This study compared 22,719 lobular carcinomas with 201,517 ductal carcinomas, dividing them into the grades: well differentiated (W), moderately differentiated (M), poorly differentiated (P), and ungraded to see if differences between comparable grades of lobular and ductal cancer were uniform, consistent with the notion the grading system provides similar information for both cancer subtypes. METHODS: The Surveillance, Epidemiology and End Results (SEER) database was used to limn relationships among grades, as respects proportions of patients with T3 tumors and nodal metastases, as well as cancer-specific survival. Taken into account were age, estrogen and progesterone receptor status, and the administration of radiotherapy. RESULTS: More lobular than ductal carcinomas were T3; grades were not homogenous, with the incidence rate ratio (IRR) comparing lobular and ductal carcinomas being 8.2 for well differentiated, 4.1 for moderately differentiated, and 2.48 for poorly differentiated. With respect to nodal metastases, the 1.16 W L:W D IRR (P < 0.05) was not explicable by chance, but both the 0.97 M L:M D IRR (P > 0.05) and the 0.96 P L:P D IRR (P > 0.05) could have been due to chance. As respects survival, neither the 1.4 P L:P D time ratio (TR) (P < 0.05) nor the 1.23 M L:M D TR (P < 0.05) could have been explained by chance; the 1.05 W L: W D (P > 0.05) might have been due to chance. CONCLUSION: Grades of lobular carcinoma imply different meanings than do grades of ductal carcinoma. Studies of breast cancer should not assume commonality with respect to grade.

Chylothorax after coronary artery bypass grafting.

Injuries to the thoracic duct and its tributaries resulting in chylothorax have been described after almost any thoracic, mediastinal, cardiac, and neck surgery. Although it remains one of the rarest complications after coronary artery bypass grafting (CABG), evidence suggests that its frequency is underestimated. New treatment options make it paramount to understand the etiology, pathophysiology, and natural course of this complication. We report a case of a right-sided chylothorax after CABG and a thorough review of the literature. The anatomy of the thoracic duct and its tributaries are discussed, with special emphasis on the anatomic variability of these structures. A treatment algorithm is proposed based on analysis of all reported cases.

Lung metastasis 21 years after initial diagnosis of osteosarcoma: a case report.

INTRODUCTION: To the best of our knowledge, this case report describes the longest disease-free interval between primary diagnosis and metastatic recurrence of an osteosarcoma. CASE PRESENTATION: A 35-year-old Caucasian American man presented with asymptomatic lung metastases 21 years after being diagnosed and treated for lower extremity osteosarcoma. He underwent curative lung resection, but 2 years thereafter developed metastatic disease in the scapula and tibia and, after resection and chemotherapy, is in remission 1 year later. CONCLUSION: This case highlights the importance of long follow-up periods and continued surveillance of osteosarcoma patients after initial curative treatment.

Best poster award: accuracy of surgery residents' interpretation of computed tomography scans in trauma.

BACKGROUND: We evaluated the accuracy of surgery residents in interpreting computed axial tomography (CT) scans of trauma patients as compared with attending radiologists. METHODS: Residents listed injuries they identified on initial CT scans of trauma patients in a time-stamped computerized system before the official report becoming available. Head, chest, and abdomen/pelvis CT scans were included. We compared the accuracy of these reads with final radiology reports. RESULTS: There were 84 injuries in 31 patients. Residents correctly identified 25 of 26 (96%) injuries to the head, 28 of 42 (67%) chest injuries, and 15 of 16 (94%) injuries to the abdomen and pelvis. The accuracy of resident reads of chest CT scans was lower (P = .035) than for other body areas. Radiologists' identified 23 of 26 (89%) head injuries, 38 of 42 (90%) chest injuries, and 14 of 16 (88%) injuries in the abdomen and pelvis CT scans. None of the missed injuries were life threatening or required immediate attention. CONCLUSIONS: Surgical residents accurately identify acute injuries on the CT scans of trauma victims.

Anterior mediastinal herniation of the transverse colon after an omental flap transposition.

Poststernotomy mediastinitis continues to be an infrequent but serious complication after cardiac surgery. We present a case of a 59-year-old man who developed a deep sternal wound infection after an emergency cardiac surgery. Omental transposition flap was used to cover the sternal defect. Several days later, the patient developed a transverse colon herniation into the anterior mediastinum that required emergency exploration and colon resection. The patient survived after a difficult hospital course. Indications, technical points, and possible complications of using omental flap transposition are discussed.

Prescribing of Controlled Substances for Non-Patients in the Educational Setting: Review of the Ethical, Legal, and Moral Dilemma for Residents.

Prescription drug abuse is an enormous problem in modern society. Studies have shown that it results in more injuries and deaths to Americans than all illegal drugs combined.1 In this review, the author discusses the prescribing of controlled substances by residents as it relates to intercollegial and other non-patient workplace encounters. Physician drug abuse, medical/legal issues regarding controlled substance prescriptions, and ethical conflicts will be discussed. These issues will be specifically addressed as they relate to the academic institutions where residents can potentially be placed in a moral, ethical and legal dilemma by supervisors and co-workers. Finally, a recommendation for an institutional policy will be suggested to help residents and other physicians recognize and deal with drug seeking behavior by coworkers. Also, a recommendation regarding strict institutional regulation of resident prescription practices regarding controlled substances will be presented.

Laparoscopic greater omentum harvesting with split-thickness skin grafting for sternal wound dehiscence.

Sternal wound dehiscence is a serious complication occasionally requiring soft tissue coverage. The greater omentum typically has been used as a last resort because of the underlying morbidity from a laparotomy. We present a case in which a laparoscopically created omental flap with subsequent split-thickness skin grafting was used to correct a large soft tissue defect that occurred after sternal wound dehiscence developed. A nonambulatory 49-year-old man who underwent coronary artery bypass grafting developed sternal wound dehiscence. Because a large soft tissue defect developed after multiple debridements, soft tissue coverage was required. A laparoscopically harvested omental flap spared this man's upper extremity musculature and provided a soft tissue bed for split-thickness skin grafting. This case helps to establish the role of laparoscopically harvested omentum. If the results suggested by this case are confirmed in a large series, omental flaps should be considered as options of first choice in the management of sternal wound dehiscence.

An ethanol protocol to prevent alcohol withdrawal syndrome.

BACKGROUND: Alcohol withdrawal syndrome (AWS) occurs in dependent patients during the initial period of sudden onset abstinence. It is usually manifested by mild symptoms such as disorientation, agitation, and tachycardia, but, if untreated, can lead to severe confusion, seizures, and even cardiovascular collapse. Prevention of AWS has been shown to improve morbidity and mortality and shorten hospital and ICU stays. We examined the efficacy of ethanol as a method of prophylaxis. STUDY DESIGN: Our patient population was divided into two groups. Group 1 consisted of surgical patients receiving alcohol prophylaxis for AWS between January 2001 and July 2004 (n=124), as identified by retrospective chart review. We then developed a protocol for the initiation, dosage, and weaning of intravenous ethanol in patients at risk for AWS, based on blood alcohol levels and clinical assessment of withdrawal symptoms and signs. Group 2 consisted of all patients treated prospectively with this protocol during the subsequent year (n=76). Patients who did not fit inclusion criteria for the protocol were excluded from analysis, resulting in 92 and 68 patients in group 1 and group 2, respectively. We compared initiation criteria, efficacy, dosage, route, duration, and referral pattern to the substance abuse clinic before and after initiation of the protocol. RESULTS: Our initial use of intravenous ethanol was very variable in dosage, duration, and indication. The protocol decreased the duration of treatment between the two groups from 7 days to a mean of 3 days. The failure rate dropped from 20% to 7%. Referral to the substance abuse clinic rose from 7.6% to 20%. The only complication was asymptomatic hyponatremia in one patient. CONCLUSIONS: Intravenous ethanol is a viable option for AWS prophylaxis when administered in a systematic protocol.

Isolated chyle duct injury in blunt trauma.

We present a case of a patient sustaining an isolated injury to the right main branch of the cysterna chyli due to a high-speed motor vehicle accident. A 42-year-old man presented after a high-speed collision. CT revealed a collection of hypodense fluid in the gallbladder fossa, which was the clue to take him to the OR. We proceeded to laparoscopic exploration, and based on the milky white color of the fluid, identified a chyle leak. In an open fashion, the retroperitoneum was explored and the injury was identified as disruption of the right lumbar branch entering the cisterna chyli, and this was ligated with silk ties. Chyle duct injury secondary to blunt trauma is a rare finding. The use of CT imaging can identify this injury. Laparoscopy can confirm the injury. Open ligation of the injured duct is the best treatment.

Bilateral external iliac artery catheter-induced vasospasm during angiography--a case report.

The occurrence of catheter-induced vasospasm of small-caliber arteries during cardiac angiography is well documented. In contrast, little documentation of catheter-induced vasospasm in large-caliber arteries exists. This case presents reproducible catheter-induced vasospasm with bilateral asymptomatic occlusion of the femoral and iliac arteries.

Delivery of a non-potassium modified maintenance solution to enhance myocardial protection in stressed neonatal hearts: a new approach.

OBJECTIVES: This study was undertaken to compare conventional cardioplegic strategies with a new approach that uses a modified non-potassium maintenance solution between cardioplegia doses in stressed neonatal hearts. METHODS: Thirty-five neonatal piglets underwent 60 minutes of ventilator hypoxia (inspired oxygen fraction 8%-10%) followed by 20 minutes of ischemia on cardiopulmonary bypass. In 10 animals bypass was discontinued without further ischemia (stress control group). The other 25 received a warm blood cardioplegic induction and were separated into 5 groups. In 5 animals cardiopulmonary bypass was discontinued without further ischemia (cardioplegia control group); the remaining 20 underwent an additional 70 minutes of cold blood cardioplegic arrest. Five received only intermittent cardioplegia every 20 minutes, whereas 15 also received cold blood maintenance infusions between cardioplegic doses (integrated strategy). In 5 of these animals the blood was unmodified, whereas in 10 a modified non-potassium "cardioplegia-like" solution was delivered either antegradely (n = 5) or retrogradely (n = 5). Myocardial function was assessed by pressure-volume loops (expressed as percentage of control); vascular function was assessed by coronary vascular resistance. RESULTS: All piglets that underwent hypoxic ischemic stress alone (controls) died. Warm induction alone (cardioplegic controls) partially repaired the stress injury. Intermittent cardioplegia preserved the depressed systolic function (end-systolic elastance 40% vs 39%), increased diastolic stiffness (255% vs 239%), reduced adenosine triphosphate (10.6 vs 12.2 microg/g tissue), and elevated coronary vascular resistance at levels identical to warm induction alone; infusing unmodified blood between cardioplegia doses (standard integrated) improved results slightly. In contrast, infusion of a cold modified solution (antegrade or retrograde) between cardioplegia doses (modified integrated) completely restored systolic function (end-systolic elastance 100% and 97%, P <.001 vs intermittent and standard integrated), only minimally increased diastolic stiffness (159% and 156%, P <.001 vs intermittent and standard integrated), restored adenosine triphosphate (18.8 and 16.6 microg/g, P <.001 vs intermittent and standard integrated), and normalized coronary vascular resistance (P <.001 vs intermittent and standard integrated). This strategy was used in 72 consecutive hypoxic patients (21 arterial switch operations, retrograde; 51 Fontan procedures, antegrade) with a 2.8% mortality. CONCLUSIONS: Infusion of a cold modified solution between cardioplegic doses (modified integrated protection) significantly improved myocardial protection in the stressed neonatal heart, was effective delivered either antegradely or retrogradely, and was used successfully for hypoxic (stressed) pediatric patients.