A Case of Left-Sided Acute Appendicitis in a 45-Year-Old Man with Situs Inversus Totalis Managed by Emergent Laparoscopic Appendectomy.

BACKGROUND Situs inversus totalis (SIT) is a rare congenital abnormality that includes mirror-image transposition of both the abdominal and the thoracic organs. It may remain undetected into adulthood until an acute medical emergency results in diagnostic imaging. This report presents a challenging case of left-sided acute appendicitis in a 45-year-old man with SIT. CASE REPORT A 45-year-old man with a medical history of gastroesophageal reflux disease, class 2 obesity, prediabetes, and elevated low-density lipoprotein cholesterol presented with severe acute abdominal pain localized in the left lower quadrant with localized tenderness, nausea, and 2 episodes of non-bloody and non-bilious emesis that started a day before the clinical encounter. Computed tomography of the abdomen and pelvis revealed previously undiagnosed congenital SIT. In addition, physical, laboratory, and radiological findings suggested early acute appendicitis with no evidence of complications. Hence, the patient was managed with an emergent laparoscopic appendectomy. Acute appendicitis was confirmed in the post-surgery histopathological examination. The post-surgery recovery was uneventful, and the patient was discharged home on the second postoperative day. CONCLUSIONS This report highlights that SIT may remain undiagnosed into adulthood and poses a challenge in the diagnosis of left-side appendicitis due to atypical symptom presentation, supporting the findings of previous case reports. Therefore, the inclusion of left-sided acute appendicitis in the differential diagnosis of abdominal pain in the left lower quadrant is warranted.

Tolerance to and Postoperative Outcomes With Early Oral Feeding Following Elective Bowel Surgery: A Systematic Review.

Although practice guidelines recommend resuming oral feeding immediately after gastrointestinal surgery, many practitioners remain reluctant to order early oral feeding (EOF). Therefore, this review aimed to clarify the tolerance to and postoperative outcomes with EOF among patients undergoing bowel surgery. A systematic review of the literature published between January 1990 and July 2022 with the time of oral intake (early or delayed until resolution of ileus) as the exposure variable was conducted using PubMed and Scopus databases. Outcomes of interest included tolerance to EOF and postoperative adverse effects or complications. After screening 1,667 research articles, 18 randomized control trials, six prospective case series, and four cohort studies met our inclusion criteria, collectively representing data from 2,647 patients in eleven countries. These studies indicate that while most patients tolerate EOF, 5-25% may not tolerate EOF until the fourth postoperative day (POD). Moreover, EOF, at best, has no advantage over delayed feeding in terms of vomiting, nausea, nasogastric tube requirement, or other postoperative complications. In addition, early return of bowel function, lower risk of diarrhea, and lower pain score with EOF are inconsistently reported, and shorter hospitalization with EOF may be limited to those who tolerate oral feeding on POD 0 or 1. Nevertheless, shorter hospitalization with EOF could reduce the cost of hospitalization. A substantial number of patients may not be able to tolerate oral feeding after bowel surgery until POD 4, and in patients who tolerate EOF, the only clear benefit is a shorter length of hospitalization.

A Severely Dilated Gallbladder With Multiple Gallstones After Concomitant Laparoscopic Sleeve Gastrectomy and Childbirth in a Hispanic Woman.

Independent studies have associated laparoscopic sleeve gastrectomy (LSG) and pregnancy with a higher incidence of gallstones, especially in Hispanic populations. However, the synergistic impact of these risk factors is currently unknown. We present the case of a 42-year-old Hispanic woman who initially identified intermittent upper right abdominal pain, which worsened over the last four days before the presentation. Abdominal ultrasound indicated hepatic steatosis, hepatomegaly, and cholelithiasis. A hydropic gallbladder with numerous gallstones, surrounding pericholecystic inflammatory changes, and mild intra-abdominal and pelvic ascites was confirmed by computed tomography. The patient underwent an uneventful robotic-assisted cholecystectomy. A gross examination of the gall bladder measuring 15.5 x 6 x 5.5 cm revealed multiple stones measuring 1.0-1.5 cm in the lumen, the largest of which was impacted in the neck. This case underscores the importance of considering ethnicity and pregnancy history while assessing the post-LSG risk of incident cholelithiasis.

Morbidity and Mortality After Rib Fracture in Elderly Patients (>65 Years Old) Compared to a Younger Cohort (≤65 Years of Age) at Doctor Hospital Renaissance Health.

BACKGROUND: Traumatic rib fracture is a major cause of morbidity and mortality. Recent studies highlight the inadequacy of age and the number of rib fractures (NRFs) to assess patients' care needs, which may unnecessarily increase the burden of intensive care unit (ICU) admissions. Therefore, we sought to clarify the clinical outcomes of patients admitted to a level I trauma center with multiple blunt-trauma rib fractures by age and fracture location. METHODS: We performed a retrospective cohort study of patients aged 18-95 admitted to Doctors Hospital at Renaissance Health with multiple rib fractures during 2017-2020. Patients with major vascular/cerebral injuries or emergency surgery from other injuries were excluded. The study population comprised 71 patients aged ≤65 and 53 patients aged >65 years. The primary study outcomes included mortality and non-home discharge. ICU length of stay (ICU-LOS), total hospital length of stay (HLOS), and days on the ventilator were the secondary outcomes. Study outcomes were also analyzed by stratifying patients by fracture location. RESULTS: Patients aged >65 years with multiple blunt-trauma rib fractures had lower mortality rates despite a higher prevalence of comorbidities but with higher rates of non-home discharges compared to younger patients. However, the mortality and non-home discharge odds ratios were not statistically significant. Also, median ICU-LOS and HLOS were numerically higher in geriatric patients but were not statistically significant. Nonetheless, younger patients required significantly more days of respiratory support than older patients. Similar differences were observed in the clinical outcome of patients ≤65 or >65 years when stratified by fracture locations. CONCLUSION: Young patients with blunt trauma rib fractures may have similar, if not worse, clinical outcomes than geriatric patients. These findings underscore the need for individual assessment of the patient's trauma severity independent of age, the number of rib fractures, or fracture location to reduce ICU burden.