An Anatomic Red Herring Found in the Diagnosis of Functional Vomiting.

This report describes the case of a previously healthy 16-year-old patient who initially presented with emesis of unknown etiology that was refractory to standard medical interventions. The initial imaging revealed duodenum inversum, a rare anatomic abnormality that provided additional diagnostic complexity to this case. Though the final diagnosis was found to be functional vomiting, this case gives an instructive review of this rare anatomic abnormality, the significant effects it may cause, and how making a diagnosis of exclusion can be challenged by unusual turns in an otherwise straightforward presentation.

A Case of Severe Hepatitis in Infant Twins With COVID-19.

We report a case of nine-month-old twins who presented with bright green diarrhea along with progressively worsening jaundice over one week. On initial evaluation, they were found to have significantly elevated liver enzymes, bilirubin, and alkaline phosphatase levels but without signs of liver failure. They were tested for multiple causes of liver injury including autoimmune and infectious etiologies, which were negative as well. Both twins were incidentally found to be positive for COVID-19 on testing per hospital protocol but did not have any respiratory symptoms. They were monitored closely during their hospital stay and showed clinical stability but with only slight improvement in abnormal lab levels. Ultimately, they were discharged with close outpatient follow-up. They demonstrated full resolution of all lab abnormalities and symptoms two months post discharge.

A Rare Case of Salmonella Osteomyelitis in Immunocompetent Toddler Without Risk Factors.

Salmonella infections are common, though rarely cause disseminated or severe disease in immunocompetent children. We present a case of severe salmonella osteomyelitis and epidural abscess in a patient without significant risk factors. This patient presented over the course of multiple visits with nonspecific symptoms of fever, malaise, and eventual joint pain. As symptoms progressed, the workup was broadened to find the eventual source of infection.

Partial Flap Loss in Gender Affirming Phalloplasty.

BACKGROUND: Flaps used in phalloplasty are larger than described for other indications, with a design that is tubularized up to two times. While the incidence of partial flap loss (PFL) is well described, current literature lacks granularity comparing donor sites and techniques with minimal discussion of etiology and management. The purpose of this study was to review our experience with PFL in phalloplasty. METHODS: This was a retrospective cohort study of patients who underwent phalloplasty by a single surgeon at a single institution between 2016 and 2020. PFL was defined as any patient requiring sharp excision of necrotic tissue and reconstruction. Patient variables (demographics, body mass index, American Society of Anesthesiologists physical status classification, comorbidities), flap variables (donor site, design, dimensions, perforator number) and intraoperative variables (use of vasopressors, intraoperative fluid volume) were collected. RESULTS: Of 76 phalloplasties, 6 patients suffered PFL (7.9%). 5/6 patients were radial forearm free flap tube-within-tube (TWT) and 1/5 patients were pedicled anterolateral thigh TWT. 4/6 cases involved the shaft only and were treated with excision ± Integra and full-thickness skin grafting. 2 cases of PFL involved the urethral extension requiring excision of the necrotic segment. CONCLUSION: PFL occurred in 7.9% of cases and was solely found in the TWT cohort. The majority of cases involved the shaft, sparing the urethral segment. Cases in the acute postoperative period appeared to be related to macrovascular venous congestion, while cases in the subacute period appeared to be due to microvascular arterial ischemia.

Masculinizing Genital Surgery: An Imaging Primer for the Radiologist.

OBJECTIVE. Masculinizing genital surgeries for transgender individuals are currently performed at only a select few centers; however, radiologists in any geographic region may be confronted with imaging studies of transgender patients. The imaging findings of internal and external genital anatomy of a transgender patient may differ substantially from the imaging findings of a cisgender patient. This article provides the surgical and anatomic basis to allow appropriate interpretation of preoperative and postoperative imaging findings. We also expand on the most common complications and associated imaging findings. CONCLUSION. As these procedures become more commonplace, radiologists will have a growing role in the care of transgender patients and will be faced with new anatomic variants and differential diagnoses. Familiarity with these anatomic variations and postoperative complications is crucial for the radiologist to provide an accurate and useful report.

Phalloplasty: techniques and outcomes.

Phalloplasty is an exceptionally complicated reconstructive procedure that attempts to create a structure that is penis-like. As patient goals vary widely, it is helpful to think about phalloplasty as a modular set of procedures that can be combined, mixed and matched to meet the needs of each individual patient while also taking into account their anatomy. Each module-but particularly the shaft and penile urethra-can be performed using a variety of techniques. To date, there is no consensus among surgeons regarding the optimum staging of the reconstructive steps. Our primary goal is to outline the most frequently performed and reported options in phallic reconstruction and outline the various considerations that go into choosing a given sequence of procedures for the specific patient. The secondary goal of this article is to describe the complications common to each of those modules and how they interact when combined.

Providing Gender Confirmation Surgery at an Academic Medical Center: Analysis of Use, Insurance Payer, and Fiscal Impact.

BACKGROUND: Expansion of insurance coverage for gender confirmation surgery (GCS) has led to a large demand for GCS in the US. We sought to determine the financial impact of providing comprehensive GCS services at an academic medical center. METHODS: This was a cross-sectional study of patients older than 18 years who presented for GCS between January 1, 2015 and July 31, 2018 at a single academic medical center. The use of GCS services and associated work relative value units is reported. Departmental and hospital-level operating (profit) margins are reported relative to other hospital services, as well as the payer mix. RESULTS: A total of 818 patients underwent 970 GCS procedures between January 2015 and July 2018. Mean (SD) age was 35.32 (12.84) years. Four hundred and ninety-three (60.3%) patients underwent a masculinizing procedure, and 325 (39.7%) had a feminizing procedure. The most commonly performed procedure was chest masculinization (n = 403). The GCS case volume grew to generate 23.8% (plastic surgery) and 17.8% (urology) of total annual departmental work relative value units, and was associated with positive operating margins after recouping new faculty hiring costs. There were positive operating margins for GCS procedures for the hospital system that compare favorably with other common procedures and admissions. Medicare and Medicaid remained the most common payer throughout the study period, but dropped from 70% in 2015 to 48% in 2018. CONCLUSIONS: We found that providing GCS at our academic medical center is profitable for both the surgical department and the hospital system. This suggests such a program can be a favorable addition to academic medical centers in the US.

Differences in Chest Measurements between the Cis-female and Trans-female Chest Exposed to Estrogen and Its Implications for Breast Augmentation.

BACKGROUND: Gender confirming primary breast augmentation is becoming more common. The purpose of this study was to compare the demographic and anatomical differences in cis-female and trans-female populations. METHODS: This was a retrospective analysis of trans-female patients and cis-female patients undergoing primary breast augmentation at a single institution. Analysis included patient demographics and preoperative chest measurements including sternal notch to nipple distance (SSN), breast width (BW), nipple to inframammary fold distance (N-IMF), and nipple to midline distance (N-M). Continuous variables were compared using independent t tests, and discrete variables were compared using Pearson's χ2 tests. RESULTS: Eighty-two trans-female and 188 cis-female patients undergoing primary breast augmentation were included. Trans-female patients were older (40.37 versus 34.07), more likely to have psychological comorbidities (50% versus 12.23%), and had a higher body mass index, 27.46 kg/m2 versus 22.88 kg/m2 (P = 1.91E-07), than cis-female patients. Cis-female patients most commonly had an ectomorph body habitus (52% versus 26%), whereas trans-female patients most commonly had an endomorph body habitus (40% versus 7%). Pseudoptosis or ptosis was more commonly seen in cis-female patients (P = 0.0056). There were significant differences in preoperative breast measurements including sternal notch to nipple distance, BW, and N-M between groups, but not in N-IMF. The ratio of BW/N-IMF was statistically significant (P = 2.65E-07 on right), indicating that the similarity in N-IMF distance did not adjust for the difference in BW. CONCLUSIONS: The trans-female and cis-female populations seeking primary breast augmentation have significant demographic and anatomical differences. This has implications for surgical decision-making and planning to optimize outcomes for trans-female patients.

What is "Nonbinary" and What Do I Need to Know? A Primer for Surgeons Providing Chest Surgery for Transgender Patients.

BACKGROUND: Most transgender research focuses on patients who identify within the gender binary of either trans-male or trans-female. This largely omits understanding of the "nonbinary" gender identity as it pertains to surgical care. OBJECTIVES: We sought to describe a single-institution experience of chest-affirming procedures performed in nonbinary patients, including patient characteristics, surgical techniques, practice pearls, and outcomes. METHODS: This was an observational study of nonbinary patients who underwent "chest-affirming surgery" from 2012 to 2017. Demographic and surgical data were collected. A postoperative questionnaire assessing quality of life and body image outcomes was administered. RESULTS: A total of 458 patients with gender dysphoria underwent chest surgery; 58 (13%) patients were nonbinary. All nonbinary patients indicated female sex was assigned at their birth (100%). The most commonly performed procedure was the double incision technique with nipple grafts (72%), followed by the double incision technique without nipple grafts (19%). On a Likert scale, patients reported improved quality of life (4.88, SD ± 0.34), comfort with exercise (4.07, SD ± 0.98), sex life (4.02, SD ± 0.92), and comfort with physical appearance with (4.97, SD ± 0.18) and without clothes (4.69, SD ± 0.47). CONCLUSIONS: Chest surgery for nonbinary patients comprises a considerable proportion of transgender surgery practice, and surgeons who provide affirming care should be familiar with the unique characteristics and treatment options for this population.

Resident autonomy in the operating room: Does gender matter?

INTRODUCTION: Previous data examining the effect of gender on surgical trainee autonomy is lacking. We hypothesized that female general surgery residents have less autonomy than males during laparoscopic cases. METHODS: We retrospectively reviewed factors associated with level of guidance needed during laparoscopic procedures as reported on intraoperative procedure feedback forms and on FLS tasks from one institution from 2013 to 2016. Data collected included resident and attending gender, level of guidance needed, PGY level, case characteristics, resident intraoperative performance, and skills lab FLS performance. Univariate and multivariate analyses were performed using a mixed-effects regression model. RESULTS: We analyzed data from 106 PGY1-PGY5 residents (51% Female) and 104 attendings (26% Female). Female resident gender was associated with more intraoperative guidance in univariate (p = 0.019) and multivariate analysis (p = 0.034). Technical performance between genders was similar. CONCLUSIONS: This study demonstrated gender-based inequality in intraoperative autonomy even after controlling for technical performance, PGY level, and case factors.