Impact of Liposomal Bupivacaine on Enhanced Recovery After Surgery Protocol for Lung Resection.

BACKGROUND: There is limited data showing the benefit of liposomal bupivacaine as part of an Enhanced Recovery After Surgery (ERAS) protocol in reducing opioid use in minimally invasive lobectomies. METHODS: A retrospective observational study compared three cohorts of patients undergoing lobectomies between January 2015 and December 2021. The control group neither received liposomal bupivacaine intraoperatively nor underwent an ERAS protocol. The liposomal bupivacaine cohort only received a nerve block, whereas the ERAS cohort received a nerve block intraoperatively and underwent an ERAS protocol. Primary outcome was post-operative opioid consumption. RESULTS: There were 433 patients in this study (n=87 for controls, n=138 for liposomal bupivacaine alone, and n=208 for ERAS/liposomal bupivacaine). There was a statistically significant difference in the amount of opioids used between the control (43 OME) and liposomal bupivacaine alone cohort (30.5 OME) (p<.001); between control vs. ERAS/liposomal bupivacaine cohort (17 OME) (p<.001); and between liposomal bupivacaine alone and ERAS/liposomal bupivacaine cohorts (p<.001). Hospital stay was not statistically different between the two groups of interest (3 days); however, hospital stay differed from the control (4 days). 30-day readmission was not significantly different between the 3 groups (p=.43). CONCLUSIONS: Liposomal bupivacaine alone as part of a larger ERAS protocol significantly reduced opioid use and hospitalization duration; however, the reduction in opioid use was much greater with incorporation of liposomal bupivacaine into an ERAS protocol rather than in isolation. Prospective studies are needed to determine reproducibility and applicability of liposomal bupivacaine for opioid use reduction in other US hospital systems.

Pancreaticoduodenal Artery Aneurysm Complicated by Median Arcuate Ligament Syndrome.

PURPOSE: To highlight median arcuate ligament syndrome as a potential cause for celiac artery stenosis and pancreaticoduodenal artery aneurysm, and describe treatment options in this setting. CASE REPORT: A 63-year-old male presented with a pancreaticoduodenal artery aneurysm and concomitant celiac artery stenosis that was treated with celiac artery stenting and aneurysm coiling. He subsequently developed stent fracture and celiac artery occlusion secondary to previously unrecognized median arcuate ligament syndrome causing reperfusion of the aneurysm. This was treated with open median arcuate ligament release and aorta to common hepatic artery bypass with good clinical result and stable 20-month surveillance imaging. CONCLUSION: It is critical to recognize median arcuate ligament syndrome as a cause of celiac artery stenosis in the setting of pancreaticoduodenal artery aneurysm given the high risk of failure of endovascular stenting. Open aorto-hepatic artery bypass and endovascular aneurysm coiling should be the preferred approach in these patients.

Lateral Compartment Syndrome From Inversion Injury.

A 17-year-old male presented for the evaluation of right calf pain after an inversion ankle sprain sustained while playing soccer 24 hours prior. On exam, he exhibited swelling and tenderness to palpation over his right calf, mild first web space numbness, and compartment pressures <30 mmHg. Magnetic resonance imaging was significant for findings of lateral compartment syndrome (CS). Upon admission, his exam worsened, prompting an anterior and lateral compartment fasciotomy. Intraoperative findings were significant for lateral CS, with findings of avulsed, nonviable muscle with associated hematoma. Postoperatively the patient had mild foot drop, which improved with physical therapy. Lateral CS rarely develops from an inversion ankle sprain. This presentation of CS is unique due to its mechanism, delayed clinical presentation, and limited signs of CS. Providers should maintain a high index of suspicion for CS in patients with this injury complex and continued pain beyond 24 hours without signs of ligamentous injury.

Portal vein thrombosis after second Pfizer/BioNTech coronavirus disease 2019 vaccine.

We have reviewed a case of portomesenteric venous thrombosis that occurred shortly after the administration of the second Pfizer/BioNTech coronavirus disease 2019 (COVID-19) vaccine and discussed the literature surrounding the subject. Our report was generated after reviewing the patient's medical records and clinical images with his written informed consent. The literature review was conducted using PubMed and Google Scholar. Portomesenteric venous thrombosis after the Pfizer/BioNTech COVID-19 vaccine has previously been reported, although infrequently. We did not find enough information, given the paucity of the reported data, to assert a causative relationship between the Pfizer/BioNTech COVID-19 vaccine and the occurrence of portomesenteric thrombosis.

Spontaneous isolated celiac and splenic artery dissection with splenic infarction.

Spontaneous isolated celiac artery dissection is considered an uncommon clinical condition. Rarer still is spontaneous isolated celiac and splenic artery dissection, with a total of 42 reported cases. There is no known definitive cause of visceral artery dissections, but risk factors include male sex, age in 5th or 6th decade, hypertension, and connective tissue disorders. The presentation varies, diagnosis is principally radiographic, and the mainstay of treatment is anticoagulation or antiplatelet therapy. Splenic infarction is a common finding with splenic artery dissection, although the strength of this association has not previously been reported. Herein we present a case of spontaneous isolated celiac and splenic artery dissection with splenic infarction that was successfully managed with blood pressure control and antiplatelet therapy. We review previous literature, principles of diagnosis and management, and incidence and outcomes of splenic infarction as it related to splenic artery dissection.

Colonic mucormycosis in solid organ transplantation: Case report and review of the literature (colonic mucormycosis after DDLT).

Mucormycosis is an opportunistic fungal infection that can occur throughout the body and carries a high mortality. Colonic mucormycosis is an uncommon form of the disease whose successful treatment relies upon a high degree of clinical suspicion and early, often empiric, therapy. We report colonic mucormycosis in a liver transplant patient and review the literature on colonic mucormycosis in solid organ transplant recipients.