Heparin-induced Thrombocytopenia (HIT) in the DOAC Era.

OBJECTIVES: Heparin-induced thrombocytopenia (HIT) is an uncommon complication of heparin therapy with significant risk for severe morbidity and mortality. We investigated the role and outcome of direct oral anticoagulants (DOACs) for the management of HIT. METHODS: After IRB approval, a retrospective review was performed identifying all patients with positive HIT serotonin-release assays between 2020 and 2022 at two hospitals. Demographic and clinical variables were collected: initial anticoagulant, dosing and indication, interval before onset of HIT, thrombotic complications, platelet nadir and recovery, direct thrombin inhibitor (DTI) and DOAC usage, and clinical outcomes. RESULTS: 15 patients were included in the study. 8 underwent a vascular procedure, 3 had cardiac surgery, 1 patient had both and was included in both groups, and 5 patients had either non-cardiac, non-vascular surgery or no surgery. 14 patients received unfractionated heparin (93% with therapeutic dosing) and 1 received prophylactic enoxaparin prior to diagnosis of HIT. The average time to diagnosis of HIT was 10.77 days after initial anticoagulation. In-hospital mortality was 27%, related to Covid-19 infection (3/4) and intracranial hemorrhage (1/4). 40% developed thrombosis (67% venous, 33% arterial) after the diagnosis of HIT. 8/11 survivors were discharged on a DOAC. With DOAC therapy, platelet counts rebounded to an average of 265K (+/- 104.6K) within an average of 2.3 days and 364K (+/- 273.9K) within 30 days after initiation of a DOAC. No recurrent thrombosis occurred after DOAC administration and only one patient had persistent thrombocytopenia within 30 days. CONCLUSIONS: Mortality and thrombosis (arterial and venous) are common complications in patients diagnosed with HIT. In patients who survive to discharge, DOACs are the most common discharge antithrombotic agent, with low rates of recurrent thrombosis and thrombocytopenia.

Measuring the Impact of a Formalized Surgical Patient Signout System.

OBJECTIVE: Routine patient signout within medical teams is an integral component of patient care. Standardized signout systems have shown lowered risks of harm and adverse outcomes to patients, however, many of these systems are difficult to utilize with surgical patients. The purpose of this study was to determine if a standardized surgical signout model would improve resident satisfaction of the signout process and improve resident preparedness for cross-covered services. DESIGN: A 16-question survey was administered to the surgical residents at a single general surgery residency program. A standardized signout using the mnemonic "CUTS" (Core problem, Updates, Things-to-do, Setbacks) was then implemented in the program. Residents retook the survey at 1, 3, and 6-month intervals to compare resident satisfaction on signout before and after the standardized signout implementation. The descriptive statistics of the survey were analyzed for trends over time, trends by resident training year, and for inferential statistics utilizing subscales. RESULTS: The descriptive statistics showed that there was an overall trend towards greater resident satisfaction with signout over time with satisfaction increasing from 41.1% to 80% in the general resident cohort. While there were no statistically significant differences, subscale analysis demonstrated greatest trends for improved satisfaction with the CUTS signout model for the PGY1 and PGY5 classes. There was additionally an increased resident preparedness for overnight events and calls, with a 27% increase in perceived preparedness "75% of the time" and a 5.5% increase in perceived preparedness "Always". There was no difference in time spent on signout after the implementation of the model. CONCLUSIONS: The surgical standardized signout model, CUTS, demonstrated that residents within a single program were more satisfied with signouts, had improved patient understanding and knowledge, and felt increased preparedness for overnight events on cross-covered patients. Further research is needed to determine the impact of the CUTS signout system on patient outcomes.

The Effect of Energy Devices, Nerve Monitors, and Drains on Thyroidectomy Outcomes: An American College of Surgeons National Surgical Quality Improvement Project Database Analysis.

The effect of energy devices, nerve monitors, and drains on thyroidectomy outcomes has been examined for each tool independently. Current literature supports the routine use of energy devices and nerve monitors and does not support the routine use of drains. The effect of these operative tools is interrelated and should be examined concurrently. The aim of this study was to describe the risk-adjusted effect of each of these tools on thyroidectomy outcomes. A retrospective analysis of 17 985 open thyroidectomy procedures was conducted using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) 2016-2018 thyroidectomy targeted procedure database. All open thyroidectomies were included. The risk-adjusted effect of energy devices, nerve monitors, and drains on 30-day outcomes was calculated by multiple logistic regression. Energy devices were associated with a decreased risk of hematoma and decreased extended length of stay without increased risk of hypocalcemia or recurrent laryngeal nerve injury. Nerve monitors were associated with a decreased risk of overall morbidity, decreased recurrent laryngeal nerve injury, and decreased extended length of stay without an increased risk of adverse outcomes. Drains were associated with an increased risk of bleeding, reoperation, and extended length of stay without decreasing hematoma. Our results support the routine use of energy devices and nerve monitors for thyroidectomy and do not support the routine use of drains for thyroidectomy.

Enormous Gallstone Discovered in the Setting of Acute-on-chronic Cholecystitis.

Biliary disease is a common surgical problem. A unique case of a 53-year-old male with an enormous gallstone precluding safe laparoscopic cholecystectomy is presented. The patient was a 53-year-old male who presented to the emergency department with a 1-day history of abdominal pain for which clinical findings were consistent with acute cholecystitis. A laparoscopic cholecystectomy was attempted, but could not be safely completed due to an enormous gallstone prohibiting attainment of the critical view of safety. The stone measured 12.2 cm × 5.2 cm × 5.2 cm. Although biliary disease is very common and its management well documented, it is rare to uncover stones larger than 5 centimeters in diameter. Clinicians should be aware that enormous gallstones require prompt surgical intervention if discovered in the elective setting to minimize future morbidity should cholecystitis develop; early elective cholecystectomy should be considered upon discovery of large gallstones to prevent encountering a gallbladder with decreased mobilization in the setting of inflamed tissues.

Metastatic neuroendocrine tumor with metastases to the right liver in a patient with absent left portal vein.

The patient is a 50-year-old female that underwent routine screening colonoscopy during which she was found to have a neuroendocrine tumor in the right colon. The patient underwent computed tomography and magnetic resonance imaging scans that demonstrated metastatic disease in segments 5 and 7 of the liver. Notably, the patient was found to have an absent left portal vein. The metastatic lesions abut the right portal vein; the right portal vein also supplies the left lobe of the liver in place of an absent left portal vein. She underwent a laparoscopic-assisted right hemicolectomy to remove the primary tumor. The patient recovered uneventfully from surgery and is currently being monitored by a multidisciplinary team regarding her metastatic disease. Neuroendocrine tumors can cause long-term effects on health and ultimately death if left untreated. We present a case of metastatic midgut neuroendocrine tumor that has metastasized to the liver in a patient with absent left portal vein.

Predictors and Consequences of Hematoma After Thyroidectomy: An American College of Surgeons National Surgical Quality Improvement Program Database Analysis.

BACKGROUND: Hematoma after thyroid surgery is a serious complication. The purpose of this study was to determine the predictors and consequences of hematoma after thyroid surgery. MATERIALS AND METHODS: A retrospective analysis of 11,552 open thyroidectomies was conducted using the American College of Surgeons National Surgical Quality Improvement Program 2016-2017 main and thyroidectomy-targeted procedure databases. Predictors of hematoma and the effect of hematoma on outcomes were analyzed by multivariate logistic regression, resulting in risk-adjusted odds ratios of hematoma and morbidity/mortality, respectively. Statistical analysis was performed using R version 3.5.1. RESULTS: We found that male gender (odds ratio 1.71, 95% confidence interval 1.25-2.32; P value 0.0007), Black race (1.89, 1.27-2.77; 0.0014), other race (1.76, 1.23-2.50; 0.0017), hypertension (1.68, 1.20-2.35; 0.0026), diabetes (1.45, 1.00-2.06; 0.0460), and bleeding disorders (3.63, 1.61-7.28; 0.0007) were independent risk factors for postoperative hematoma. The use of an energy device for hemostasis (0.63, 0.46-0.87; 0.0041) was independently associated with decreased hematoma rate. Postoperative hematoma was an independent risk factor for overall morbidity (3.04, 2.21-4.15; <0.0001), hypocalcemia (1.73, 1.08-2.66, 0.0162), recurrent laryngeal nerve injury (2.42, 1.57-3.60, <0.0001), pulmonary morbidity (18.91, 10.13-34.16, <0.0001), wound morbidity (10.61, 5.54-19.02, <0.0001), readmission (5.23, 3.34-7.92, <0.0001), return to operating room (90.73, 62.62-131.97; <0.0001), and length of stay greater than the median (5.10, 3.62-7.15, <0.0001). CONCLUSIONS: Identified by this study are the predictors of postthyroidectomy hematoma and the consequences thereof. Notably, the use of energy devices for hemostasis was shown to be protective of postoperative hematoma. The results of this study may guide pre- and intra-operative decision-making for thyroidectomy to reduce rates of postoperative hematoma.

Predictors and consequences of recurrent laryngeal nerve injury during open thyroidectomy: An American College of Surgeons National Surgical Quality Improvement Project database analysis.

BACKGROUND: Recurrent laryngeal nerve (RLN) injury is a serious complication of thyroidectomy. The purpose of this study is to determine the predictors and consequences of RLN injury during thyroidectomy. METHODS: A retrospective analysis was conducted using the ACS-NSQIP 2016-2017 main and thyroidectomy targeted procedure databases. Data was analyzed by multivariate logistic regression resulting in risk-adjusted odds ratios of RLN injury and morbidity/mortality. RESULTS: Age ≥65, black race, neoplastic indication, total or subtotal thyroidectomy, concurrent neck surgery, operation time > median, hypoalbuminemia, and anemia were associated with RLN injury. Use of intraoperative nerve monitoring was associated with decreased RLN injuries. RLN injury is a risk factor for overall morbidity, hypocalcemia, hematoma, pulmonary morbidity, readmission, reoperation, and length of stay > median. CONCLUSION: Several predictors of RLN injury during thyroidectomy are identified, while use of intraoperative nerve monitoring was associated with a decreased risk of RLN injury. RLN injury is associated increased postoperative complications.

Successful nonoperative management of mycotic radial artery pseudoaneurysm in patient with absent superficial palmar arch.

We present the case of a patient in whom a mycotic radial artery false aneurysm developed after removal of a radial arterial line; anatomic constraints precluded simple resection and ligation of the infected artery. The patient was successfully treated nonoperatively by compression bandaging, intravenous antifungals, and serial imaging. This case represents an alternative to standard management of a mycotic aneurysm and demonstrates the importance of an individualized approach to patient care.