Seat Belt Injury and Efferent Loop Laceration Following a Single Anastomosis Duodenal Switch: A Case Report.

Blunt abdominal trauma patients who have had prior bariatric procedures may present a diagnostic and therapeutic challenge. The single anastomosis duodenal-ileal bypass with sleeve (SADI-S) is a modified duodenal switch procedure that is relatively uncommon. This case report describes a patient who previously underwent a SADI-S for the management of obesity and subsequently sustained a seat belt injury in a motor vehicle collision resulting in a laceration of the efferent loop. The patient presented with symptoms of acute abdominal pain and was diagnosed through imaging studies. Prompt surgical intervention was performed with resection and primary anastomosis of the damaged section of the jejunum, and repair of a large mesenteric laceration. We discuss the importance of early recognition and intraoperative decision-making in the case of this patient concerning her SADI-S.

Steering Wheel Aftermarket Rhinestone Emblem Projectile Injury in a Motor Vehicle Collision: A Case Report.

Motor vehicle collisions are a leading cause of morbidity and mortality within the United States. Safety devices such as seatbelts and airbags have significantly reduced mortality rates for drivers. Some drivers personalize their vehicles with inexpensive items that may cause significant injury during vehicular collisions. We present a case of a face and neck penetrating injury from a metal aftermarket rhinestone emblem attached to the steering wheel during a motor vehicle collision. A 43-year-old female was involved in an accident where the airbag had deployed and projected two pieces of the metal emblem at her face and neck. The fragment in the neck was removed at the bedside, while that in the face required removal in the operating room. She recovered well postoperatively and was discharged the same day. This case highlights the potential for the dangers caused by aftermarket rhinestone emblems on steering wheels. We recommend that increased national advisories and legislative actions be considered to limit the use of these emblems.

The Great Debate: Robotic vs Traditional Surgical Approach in the Acute Care Setting.

Robotic surgery was first introduced in the 1980s as a system to aid patients in the battlefield. Since then, robotic surgery has become an important minimally invasive tool and plays an important role in elective surgery among various surgical specialties. However, the role for robotic surgery in the emergent setting is not well established or studied. Robotic surgery has been shown to be advantageous to both patients and operating surgeons. Though limited, studies have found robotic surgery in the acute setting to be safe for patients. These studies found robotic surgery to have improved perioperative outcomes when compared to an open or laparoscopic approach. Additionally, the robotic platform is thought to be an effective tool to prevent conversion to open procedures in emergent settings. Although some studies demonstrate advantages to robotic acute surgery, others have shown increased complications with robotic acute surgery or no distinct advantage when comparing robotic to laparoscopic surgery. Additionally, some of the published papers supporting the use of robotic surgery in the emergent setting may have a degree of bias favoring the robotic platform. Robotic surgery is a mainstay in minimally invasive elective surgery and gaining popularity among patients and surgeons. There are pros and cons to the adaptation of the robotic platform in the acute care setting. Additional large population studies are indicated to determine the true role of the robotic platform in the emergent setting.

Safety and effectiveness of single- versus double-anastomosis duodenal switch at a single institution.

BACKGROUND: Biliopancreatic diversion with duodenal switch (DS) is known to be superior in weight loss to other bariatric procedures, but with the disadvantage of increased complication rates. Single-anastomosis duodenal-ileal bypass (SADI-S) is reported to have similar weight loss with lower complication rates compared with traditional DS. OBJECTIVES: The aim of this study was to compare weight loss and complication rate between SADI-S and double-anastomosis DS at a single institution. SETTING: Academic hospital, United States. METHODS: A retrospective chart review was performed on 185 patients who underwent laparoscopic or robot-assisted laparoscopic DS between March 1, 2015 and December 10, 2017. A total of 111 patients had SADI-S, and 74 patients underwent double-anastomosis DS. RESULTS: Baseline patient characteristics were comparable between the 2 groups. The mean preoperative body mass index was 56.3 kg/m2 and 54.4 kg/m2 in SADI-S and double-anastomosis DS patients, respectively. Thirteen (11.7%) and 4 (5.4%) patients were readmitted within 30 days after SADI-S and double-anastomosis DS, respectively (P = .16). Percentage of total weight loss was 22.0%, 38.5%, and 44.2% in the SADI-S group and 20.2%, 38.0%, and 48.4% in the double-anastomosis DS group at 6, 12, and 24 months, respectively. The majority of patients had vitamin A and E levels in the normal range. However, 40% to 60% of the patients had low levels of vitamin D after the procedure. CONCLUSIONS: SADI-S and double-anastomosis DS are comparable in terms of weight loss and complication rate. However, close nutritional follow-up is warranted for both procedures.

Learning Curve of Robotic Lobectomy for Early-Stage Non-Small Cell Lung Cancer by a Thoracic Surgeon Adept in Open Lobectomy.

OBJECTIVE: The aim of the study was to characterize the clinical outcomes and learning curve during the adoption of a robotic platform for lobectomy for early-stage non-small cell lung cancer by a thoracic surgeon experienced in open thoracotomy. METHODS: Retrospective review of 157 consecutive patients (57 open thoracotomies, 100 robotic lobectomies) treated with lobectomy for clinical stage I or II non-small cell lung cancer between 2007 and 2014. Clinical outcomes were compared between the open thoracotomy group and five consecutive groups of 20 robotic lobectomies. We used the following six metrics to evaluate learning curve: operative time, conversion to open, estimated blood loss, hospitalization duration, overall morbidity, and pathologic nodal upstaging. RESULTS: The robotic and open thoracotomy groups had equivalent preoperative characteristics, except for a higher proportion of clinical stage IA patients in the robotic cohort. The robotic group, as a whole, had lower intraoperative blood loss, less overall morbidity, shorter chest tube duration, and shorter length of hospital stay as compared with the open thoracotomy group. Operative time demonstrated a bimodal learning curve. Conversion rate diminished from 22.5% in the first two robotic groups to 6.7% in the latter three groups. The rate of pathologic nodal upstaging was statistically equivalent to the open thoracotomy group. CONCLUSIONS: Adoption of a robotic platform for lobectomy for early-stage non-small cell lung cancer by an experienced open thoracic surgeon is safe and feasible, with fewer complications, less blood loss, and equivalent nodal sampling rate even during the learning curve. The conversion to open rate significantly dropped after the first 40 robotic lobectomies, and operative time for robotic lobectomy approached open thoracotomy after 60 cases, after a bimodal curve.

Cirrhosis following single anastomosis duodeno-ileal switch: A case report.

INTRODUCTION: Single anastomosis duodeno-ileal switch (SADI-S) involves a single, loop duodeno-ileal anastomosis with omission of the traditional Roux-en-Y distal ileo-ileal anastomosis. Not much has been published on the complications of SADI-S. PRESENTATION OF CASE: The patient is a 40 year-old male who underwent robot-assisted SADI-S three years prior. At the time of surgery, his body mass index (BMI) was 69 kg/m2. His BMI was 31 kg/m2 at the time of presentation. Computed tomography of the abdomen and pelvis showed a liver with a nodular appearance and moderate ascites throughout the abdomen and above the liver. Liver function showed AST 73 U/L, ALT 63 U/L, alkaline phosphatase 128 U/L, bilirubin 1.0 mg/dL, and albumin 2.8 g/dL. He underwent diagnostic and therapeutic paracentesis with removal of 6L of fluid that was negative for infection or malignant cells. Esophagogastroduodenoscopy showed grade I esophageal varices and diffuse mild gastritis. DISCUSSION: Mild hepatic dysfunction is common after biliopancreatic diversion and usually manifests as a temporary rise in liver enzymes that peak several months after surgery and normalize by one year. Cirrhosis and liver failure are rare sequelae that may develop at any time after surgery. Potential mechanisms include the absorption of hepatotoxic compounds from the bypassed small intestine in the context of bacterial overgrowth, protein malnutrition, and excessive free fatty acid mobilization causing steatosis and oxidative damage to hepatocytes. CONCLUSION: Close laboratory monitoring is important after SADI-S in order to detect worsening hepatic dysfunction, which may occur many years after the surgery in the absence of other etiologies for liver failure.

Less Than Total Excision of Infected Prosthetic PTFE Graft Does Not Increase the Risk of Reinfection.

BACKGROUND: Traditional treatment of infected polytetrafluoroethylene (PTFE) grafts consist of removal of the entire prosthesis. Closure of the native vessels may compromise vascular patency. We examined the outcomes for patients in whom a PTFE remnant of an infected graft was retained on the vessel. METHODS: We reviewed the operating room log from 2000 to 2011 and identified all patients who had partial removal of an infected PTFE graft used for hemodialysis or peripheral bypass. These patients were examined for subsequent complications. RESULTS: Twenty-seven patients underwent 30 partial graft excisions with mean follow-up of 27 months. A total of 17% (5 of 30) of the partial graft resection procedures resulted in complications. Of 48 total remnants left behind at the arterial or venous anastomoses, reinfection occurred in 15%. CONCLUSIONS: Leaving a well-incorporated small 1-to 5-mm PTFE remnant at the arterial or venous anastomoses can be performed safely with a low risk of complications.

Topical platelet-derived growth factor vs placebo therapy of diabetic foot ulcers offloaded with windowed casts: a randomized, controlled trial.

OBJECTIVE: This study sought to compare the efficacy of topical platelet derived growth factor (Regranex, Smith and Nephew, London, UK) (test group) to placebo (control group) in treating diabetic foot ulcers. All subjects had a short leg walking cast with a window fashioned in the cast over the site of the ulcer. METHODS: Forty-six subjects were randomized (double-blind) 1:1 to the test or control group and treated for up to 4 months. Subjects had Wagner grade I ulcers with wound area of 1 cm2 to 16 cm2 without severe peripheral arterial disease, osteomyelitis, or any infection requiring antibiotics. Study medication was applied daily and casts changed approximately every 14 days. RESULTS: Of the 46 subjects randomized, 38 either healed or completed 16 weeks of therapy without healing. Eight subjects dropped out prior to 16 weeks. Based on intention-to-treat, 12 of 23 (52%) test group subjects healed before 16 weeks compared to 13 of 23 (57%) control group subjects (not significant). Regression analysis demonstrated that slower healing was associated with larger initial wound size (hazard radio [HR] = 0.997, 95% confidence interval [CI]: 0.995-1.00, P = 0.028) and excessive wound drainage (HR = 0.346, 95% CI: 0.126-0.948, P = 0.039). Excluding the patients who dropped out, 25 of 38 (66%) subjects healed by 4 months. Three additional subjects healed with casts that were worn longer than 4 months, for an overall rate of 74% at 9 months. Five subjects developed cast burns, and 3 patients required amputation. CONCLUSION: Topical platelet derived growth factor does not appear to significantly improve healing of Wagner grade I diabetic foot ulcers that are treated by offloading with a short leg walking cast. Excellent healing rates may be achieved with casting alone.

Stent salvage of arteriovenous fistulas and grafts.

OBJECTIVES: This study analyzes our experience using stents to salvage dysfunctional hemodialysis access sites at a single institution. METHODS: We examined the outcomes of 42 consecutive patients who had covered (36 patients) or bare-metal (9 patients) stent intervention for hemodialysis access salvage. RESULTS: Of our 42 male patients, 11 had stent salvage of an arteriovenous fistula, which yielded postintervention primary and secondary 6-month patencies of 27% and 55%, respectively. For 31 patients with arteriovenous grafts, the postintervention primary and secondary 6-month patencies were 26% and 29%, respectively. Patency rates were superior for stents placed in patent access sites, in fistulas compared to grafts, and when stents were placed in forearm sites although only the latter achieved statistical significance. CONCLUSIONS: Stents can extend patency for the thrombosed or failing arteriovenous access, but results are poor once thrombosis has occurred. Stent placement appears to be more effective in fistulas compared to grafts.

Surveillance computed tomographic arteriogram does not change management before 3 years in patients who have a normal post-EVAR study.

BACKGROUND: Standard surveillance after endovascular abdominal aortic aneurysm repair (EVAR) consists of periodic computed tomographic arteriographies (CTAs) usually performed at postoperative months 1, 6, and 12, and then annually. This imaging regimen is expensive and exposes patients to the hazards of radiation and intravenous contrast. We hypothesized that a normal 1-month CTA after EVAR with no endoleak or other significant abnormality predicts a low rate of future complications, which would justify a reduction in frequency of subsequent CTAs. METHODS: We identified 106 consecutive patients who underwent EVAR at a single hospital from 2003 to 2010 and reviewed all their CTAs. Fifteen patients for whom we could not review a postoperative CTA were excluded. Of the remaining 91 patients, 70 (76.9%) had no abnormality on their CTA at 1 month after EVAR. The medical records of these 70 patients were analyzed for subsequent complications and interventions related to EVAR. RESULTS: The mean patient follow-up was 3.4 ± 2.1 years. Five of the 70 (7.1%) patients with a normal post-EVAR CTA developed late complications consisting of 1 type I endoleak, 3 type II endoleaks, and 1 case of endotension. Only the type I endoleak and one of the type II endoleaks met criteria for intervention, and in both cases, the endoleaks were discovered >3 years after EVAR. Log-rank test showed a statistically significant increased freedom from aneurysm sac expansion in patients with a normal compared with an abnormal 1-month CTA (P < 0.001). CONCLUSIONS: For patients who have a normal CTA with no endoleak 1 month after EVAR, it is reasonable to consider less-frequent CTA surveillance because no significant complications requiring intervention occurred before 3 years. This would decrease unnecessary CTAs and health care expenditures as well as minimize patient exposure to radiation and intravenous contrast.