Could blunt trauma lead to a double lumen esophagus?

INTRODUCTION AND IMPORTANCE: Esophageal rupture and perforation are serious complications of blunt abdominal trauma. Early diagnosis and intervention is key for patient survival. Studies have reported that mortality of patients with esophageal perforation can be as high as 20-40 % (Schweigert et al., 2016; Deng et al., 2021 [1, 2]). We present a patient with suspected esophageal perforation after a blunt trauma identified by esophagogastroduodenoscopy (EGD) as the presence of a second gastroesophageal lumen concerning for esophagogastric fistula. CASE PRESENTATION: Our patient is a 17-year-old male with no past medical history who was brought in from an outside facility status post electric bike accident. CT imaging from an outside hospital showed concern for possible esophageal rupture. On arrival, he was in no acute distress. Patient underwent a fluoroscopy upper GI series which showed extravasation of fluid outside the lumen, indicating an esophageal injury. Patient was evaluated by Gastroenterology and Cardiothoracic surgery, who agreed on an empiric course of piperacillin/tazobactam and fluconazole for prophylaxis in the setting of suspected esophageal rupture. Patient underwent an esophagram with EGD which demonstrated a 2nd false lumen from 40 to 45 cm. This appeared to be from incomplete avulsion of the submucosal space. No contrast extravasation was seen with the esophagram. CLINICAL DISCUSSION: To date, there has been no published case of trauma induced formation of a double lumen esophagus. Our patient presented with no previous history to suggest chronic or congenital double lumen of the esophagus. CONCLUSION: When considering esophageal rupture, the possibility of the formation of an esophago-gastric fistula should be considered via external traumatic insult.

Surgical and Endovascular Management of Extracranial Carotid Artery Aneurysms, Outcomes From the American College of Surgeons, National Surgical Quality Improvement Program.

OBJECTIVES: Extracranial carotid artery aneurysms (ECAA) are rare and consequentially understudied; yet multiple management strategies for ECAA have been pursued. The goal of this study was to compare rates of stroke and cardiac events following surgical or endovascular management of ECAA utilizing the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP). METHODS: The ACS-NSQIP database was queried for patients with both selected procedure codes and diagnostic codes specific for ECAA. 139 patients, 0.2% of carotid procedures, were located within ACS-NSQIP from 2013-2017. RESULTS: The endovascular group (n = 19) had a higher proportion of emergency procedures than the open surgical group (n = 120). Post-operative strokes in the endovascular group (n = 3, 15.8%) were not significantly higher than the open surgical group (n = 5, 4.2%; P = 0.078). One cardiac event (0.7%) in the cohort occurred in the surgical group. DISCUSSION: This study provides insight into trends in national management of ECAA. Post-operative stroke rates trended higher with endovascular approaches, perhaps due to traumatic presentation as this group had a higher proportion of emergency procedures. Additionally, this study suggests patients with ECAA may have less cardiac burden than their peers with carotid stenosis.

Compliance With Surgical Oncology Specialty Care at a Safety Net Facility.

BACKGROUND: Social determinants of health challenge in at-risk patients seen in safety net facilities. STUDY DESIGN: We performed a retrospective review of surgical oncology specialty clinic referrals at a safety net institution evaluating referral compliance and times to first appointment and initiation of definitive treatment. Main outcomes measured included completion of initial visit, initiation of definitive treatment, time from referral to first appointment, and time from first appointment to initiation of definitive treatment. RESULTS: Of 189 new referrals, English was not spoken by 52.4% and 69.4% were Hispanic. Patients presented without insurance in 39.2% of cases. Electronic patient portal was accessed by 31.6% of patients. Of all new referrals, 55.0% arrived for initial consultation and 53.4% initiated definitive treatment. Malignant diagnosis (P < .0001) and lack of insurance (P = .01) were associated with completing initial consultation. Initiation of definitive treatment was associated with not speaking English (P = .03), malignant diagnosis (P < .0001), and lack of insurance (P = .03). Times to first appointment and initiation of definitive treatment were not significantly affected by race/ethnicity, language, insurance, treatment recommended, or electronic patient portal access. CONCLUSION: Access to surgical oncology care for at-risk patients at a safety net facility is not adversely affected by lack of insurance, primary spoken language, or race/ethnicity. However, a significant proportion of all patients fail to complete the initial consultation and definitive treatment. Lessons learned from safety net facilities may help to inform disparities in health care found elsewhere.

Associate Program Directors in Surgery: A Select Group of Surgical Educators.

OBJECTIVE: The role of the Associate Program Director (APD) within surgical education is not clearly defined or regulated by the Accreditation Council for Graduate Medical Education, often leading to variations in the responsibilities among institutions. Required credentials are not specified and compensation and protected time are not regulated resulting in large discrepancies among institutions. APDs are brought into the fold of surgical education to parcel out the escalating responsibilities of program director (PD). The Association of Program Directors in Surgery, Associate Program Directors Committee sent a survey to all APDs to better understand the role of the APDs within the hierarchy of surgical education. DESIGN: A survey was sent to all 235 general surgery residency programs through the Association of Program Directors in Surgery list serve. The survey collected information on APD demographics, characteristics, and program information, qualifications of the APD, time commitment and compensation, administrative duties, and projected career track. SETTING: General surgery residency programs within the United States. PARTICIPANTS: 108 Associate Program Directors in general surgery RESULTS: A total of 108 (46%) APDs responded to the survey. Seventy-three (70.2%) of the APD's were males. Most (77.8%) were in practice for more than 5 years, and 69% were at a university-based program. Most of the respondents felt that the administrative and curricular tasks were appropriately distributed between the APD and PD and many shared tasks with the PD. A total of 44.6% were on the path to become a future PD at their institution. An equal number of APDs (42.6%) were compensated above their base salary for being an APD vs no compensation at all; however, 16 (14.8%) had a reduced clinical load as part of their compensation for being an APD. CONCLUSION: This is the first study to describe the characteristics of APDs within the hierarchy of surgical education. Our data demonstrate that APDs have a substantial role in the function of a residency program and they need to be developed to better define their position in the program leadership.

Characteristics and Correlates of Word Use in Physician-Patient Communication.

BACKGROUND: Numerous studies have described and evaluated communication in healthcare contexts, but these studies have focused on broad content and complex units of behavior. Growing evidence reveals the predictive power and importance of precise linguistic characteristics of communication. PURPOSE: This study aims to document characteristics, predictors, and correlates of word use within specific linguistic categories by physicians and patients during a healthcare visit. METHODS: Conversations between patients (n = 145) and their physician (n = 6) were audio recorded, transcribed, and analyzed using Linguistic Inquiry Word Count software. Patients also completed questionnaires prior to and immediately following the visit and (for a subset of patients) at a follow-up visit, which assessed patients' demographics, how much they liked the physician, and self-reported adherence. Physicians completed a questionnaire following the initial visit that assessed the patient's health status, the physician's optimism regarding the upcoming treatment, and satisfaction with the productivity of the visit. RESULTS: Patients and physicians differed in the extent of their word use in key linguistic categories, while also maintaining significant linguistic synchrony. Demographic characteristics and health status predicted variability in patients' and physicians' word use, and word use predicted key visit outcomes. Most notably, patients liked their physician more when physicians used fewer negative emotion words and were less adherent when physicians used more singular first-person pronouns. CONCLUSIONS: These findings reveal patterns in the way physicians speak to patients who vary in their demographic characteristics and health status and point to potentially fruitful targets for linguistic interventions with both physicians and patients.

Dialysis Access Surgery: Does Anesthesia Type Affect Maturation and Complication Rates?

BACKGROUND: Creation of an arteriovenous fistula (AVF) is the preferred method of establishing long-term dialysis access. There are multiple anesthetic techniques used for patients undergoing this surgery including general endotracheal intubation, laryngeal mask airway, regional anesthesia with nerve blocks, and monitored anesthesia care with local infiltration. It is unclear what effect the method of anesthesia has on AVF creation success rate. It is our objective to determine if anesthesia type affects success of these surgeries defined by complication and maturation rates. METHODS: A retrospective review was performed in a single institution, single surgeon study of 253 patients who underwent AVF creation between January 2003 and December 2010. Patients were cross analyzed between 3 anesthesia types (General Endotracheal Intubation, Laryngeal Mask Airway and Local Infiltration with Monitored Anesthesia Care) and AVF creation surgeries (radiocephalic, brachiocephalic, and basilic vein transposition). No patients had regional anesthesia performed. Demographic data including comorbidities and risk factors were stratified among all categories. Analysis of variance, chi-squared testing, and Fisher's exact P testing was performed across all anesthesia types and specific operations and measured according to success of fistula maturation and complication rates (including death within 30 days, myocardial infarction within 30 days, respiratory insufficiency, venous hypertension, wound infections, neuropathy, and vascular steal syndrome). RESULTS: There were no significant differences in maturation rate in terms of all 3 anesthesia types for radiocephalic (P = 0.191), brachiocephalic (P = 0.191), and basilic vein transposition surgeries (P = 0.305). In addition, there were no differences in complication rates between the surgeries and the 3 types of anesthesia (P = 0.557). CONCLUSIONS: Our study shows that despite anesthesia type, outcomes in terms of maturation and complication rate are not statistically different in AVF creation surgeries. The use of monitored anesthesia care with local anesthesia may improve operative efficiency in terms of time in the operating room and in the recovery unit and therefore may be the preferred method of anesthesia. This recommendation may also parallel the preference to avoid general anesthesia in a patient population with more medical comorbidities. It is our conclusion that dialysis access surgery should therefore be performed under local anesthesia with monitored anesthesia care.

Preoperative carotid duplex findings predict carotid stump pressures during endarterectomy in symptomatic but not asymptomatic patients.

BACKGROUND: Carotid stump pressure (CSP) is frequently measured to determine the need for shunt use during carotid endarterectomy (CEA). We hypothesized that the preoperative carotid duplex examination correlates with preoperative symptoms and intraoperative CSP. METHODS: Patients undergoing CEA over a 7-year period were identified from our vascular registry. CEA was performed with selective shunting on the basis of intraoperative CSP <30 mm Hg regardless of symptoms or contralateral internal carotid artery (ICA) stenosis. The preoperative duplex was categorized by ipsilateral and contralateral ICA diameter-reduction stenosis (<15%, 15-45%, 45-70%, 70-99% [severe] and occluded), and the direction of vertebral artery flow. The relationships among preoperative duplex findings, symptom status, and CSP were evaluated using unpaired t-test and Chi-square analysis. RESULTS: A total of 303 CEAs were performed. Stump pressures were documented in 284 patients, which comprised the study population. Asymptomatic severe stenosis was the indication for CEA in 179 cases (59.1%). Symptomatic patients (Sx) had significantly lower stump pressures than asymptomatic (ASx) patients (40.72 ± 16.27 vs. 45.8 ± 17.64 mm Hg, p = 0.0167). Fifty-seven patients (19%) had contralateral severe ICA stenosis or occlusion. Contralateral ICA stenosis or occlusion had significantly lower CSP than those with lesser degrees of stenosis (39.24 ± 15 vs. 44.82 ± 17.62 mm Hg, p = 0.0267). Contralateral ICA severe stenosis or occlusion correlated with lower CSP in Sx patients (32.05 ± 8.24 vs. 42.92 ± 16.95 mm Hg, p = 0.038) but not in ASx patients (43.2 ± 16 vs. 46.29 ± 17.5 mm Hg, p = 0.39). CSP was <30 mm Hg in 63% of Sx patients and 24% of ASx patients (p = 0.012). Overall shunt usage was 84/2,842 (9.5%). Perioperative stroke and death rate was 2.7%. Perioperative stroke did not correlate with the presence of contralateral occlusion, or severity of contralateral stenosis. CONCLUSIONS: Symptomatic patients undergoing CEA have lower stump pressures than ASx patients overall and also in the presence of contralateral disease. The incidence of perioperative stroke was not predicted by severity of contralateral disease. A strategy of selective shunting seems appropriate even in Sx patients with contralateral severe stenosis or occlusion. Although a high-risk cohort for perioperative neurologic events exists and may include those with symptomatic disease and contralateral severe stenosis or occlusion, further study is warranted to define the patients who will clinically benefit from shunt placement.

Rupture of an abdominal aortic aneurysm following nonaccidental blunt abdominal trauma.

A 78-year-old woman presented to our trauma center with an initial, erroneous history of a ground-level fall. Further investigation revealed that the patient had been assaulted by her husband immediately prior to presentation. The initial abdominal examination was benign, and the patient was hemodynamically stable. The patient was found to have a large subdural hematoma (SDH). Following open evacuation of the SDH, the patient developed ongoing hemodynamic instability. Further evaluation with computed tomography of the abdomen and pelvis uncovered the diagnosis of a 6 cm abdominal aortic aneurysm (AAA) with a large retroperitoneal hematoma. The patient underwent emergent repair of the ruptured AAA. There were no other significant intra-abdominal injuries, and the patient had an uneventful recovery. This case highlights the need for thorough evaluation of the trauma patient and recognition of the possibility of coexistent AAA in the elderly trauma patient. We believe that this is the first reported case of a ruptured AAA following nonaccidental blunt abdominal trauma.

A prospective analysis of critical limb ischemia: factors leading to major primary amputation versus revascularization.

In our aging population, primary major amputations (AMP, below-knee or above-knee) continue to be performed despite advances in revascularization. We hypothesized that not only patient comorbidities but also the system of health-care delivery affected the treatment of patients with critical limb ischemia (CLI). A prospective analysis of patients presenting with CLI was undertaken to determine whether patient-specific factors or healthcare delivery factors (system-related) influenced treatment with primary AMP versus lower extremity revascularization (LER). The patient-specific factors age, gender, race/ethnicity, presence of coronary artery disease, cerebrovascular disease, tobacco use, diabetes mellitus (DM), dialysis dependence (end-stage renal disease, ESRD), hypertension, hyperlipidemia, stage of CLI (rest pain, minor or major tissue loss), history of revascularization, and functional status (living situation and ambulatory status) were recorded. The system-related factors time from onset of CLI to vascular surgery evaluation and type of insurance (managed care/other insurance) were also noted. The influence of patient-specific and system-related factors on the primary treatment modality (AMP versus LER) was determined with univariate and multivariate analyses. A total of 224 patients presented with CLI between March 1, 2001, and March 1, 2005. Patients were treated with primary major AMP in 97 cases (43%) and revascularization in 127 cases (57%). On univariate analysis, nonwhite race/ethnicity, DM, ESRD, major tissue loss, dependent living situation, and nonambulatory status were all significant predictors of AMP versus LER (all P < 0.01). On multivariate analysis, major tissue loss, ESRD, DM, and nonambulatory status remained independent predictors of AMP versus LER (all P < 0.05). The system-related factors of time to vascular surgery evaluation (mean 8.6 weeks, 7.1 vs. 9.3 weeks AMP versus LER, P = 0.60) and type of insurance (managed care, 17% vs. 24% AMP vs. LER, P = 0.15) had no influence on treatment. Fifty-four percent of all primary major AMPs were performed due to extensive gangrene or infection present at initial vascular evaluation which precluded limb salvage. Major tissue loss, ESRD, DM, and nonambulatory status are all independent predictors of treatment with primary AMP as opposed to revascularization. Treatment of CLI is determined by patient-specific factors and does not appear to be adversely influenced by system-related factors. Efforts toward improving limb salvage may be best directed at aggressive treatment of medical comorbidities to prevent the late complications of CLI. Earlier recognition of tissue loss and referral to the vascular specialist may lead to improved limb salvage.

Chronic ergot toxicity presenting with bilateral external iliac artery dissection and lower extremity rest pain.

Chronic use of ergot alkaloids has been recognized as a rare cause of lower extremity ischemia. Most patients with ergot toxicity present with symptoms of lower extremity claudication. Herein we present a woman with bilateral lower extremity rest pain and a history of chronic ergot use for migraine headaches. Arteriography demonstrated extensive pruning of the distal arterial tree along with bilateral external iliac artery dissections - a finding that is not often associated with young, normotensive patients with chronic ergot toxicity. This patient was treated with endovascular stenting of the dissections along with cessation of ergot. Her symptoms improved markedly, and follow-up arteriography 6 weeks later demonstrated resolution of the iliac dissections along with restoration of nearly normal lower extremity runoff vessels. Discontinuation of ergot-containing products and cessation of tobacco and caffeine use is the cornerstone of therapy in chronic ergot toxicity. The association of ergot toxicity and iliac dissection has not been previously described. Endovascular or surgical interventions may be considered in patients with ergot toxicity for specific indications or those whose symptoms progress despite conservative management.