Gastrointestinal complications after cardiac surgery.

Gastrointestinal complications after cardiac surgery are relatively rare entities but carry a high mortality. We identified over 70 articles written since 2010 using the PubMed database. We included 40 in our review. The most common complications include paralytic ileus, gastrointestinal bleeding, and bowel ischemia. Patients who undergo cardiac procedures are at risk for poor perfusion of the gastrointestinal tract and, thus, at risk for resulting complications. Risk factors for these complications include peri-operative use of vasopressors, prolonged operative time, and the time of cardiopulmonary bypass. Presentation of gastrointestinal complications tends to differ as patients after open heart surgery can remain intubated, and exams can be limited. Early recognition and aggressive therapy are paramount. We aim to provide a review that will help the reader get familiar with the most common gastrointestinal complications that can negatively affect outcomes after cardiac surgery.

Acquired Bronchobiliary Fistula in a Young Adult Patient With Sepsis: A Case Report.

Bronchobiliary fistula (BBF) is a rare, highly morbid condition that results from an abnormal connection between biliary channels and the bronchial tree. In the past, this condition has been known to be caused by untreated hydatid cysts or hepatic abscesses that can erode through the diaphragm into the pleural cavity and bronchial tree, creating fistulation. However, the condition's spectrum has changed in recent years, and BBFs have also become associated with neoplasm, iatrogenic causes, and trauma. Cases of BBF are treated differently, either with simple conservative management or invasive surgery. We present a case of a 46-year-old male initially presenting with sepsis, who was found to have a BBF. The diagnosis was made after a hepatobiliary iminodiacetic acid scan showed the flow of a tracer in the lung fields. The condition was likely due to acute cholecystitis and prior biliary instrumentation. The patient was treated successfully with percutaneous cholecystostomy tube insertion followed by elective laparoscopic cholecystectomy several weeks after hospital discharge.

Leptomeningeal Carcinomatosis: A Rare Presentation of Perforated Gastric Cancer.

Leptomeningeal carcinomatosis (LMC) or leptomeningeal metastasis is defined as metastasis to the pia mater, arachnoid, and subarachnoid space. Only very few patients with cancer have LMC. In the practice of general surgeons, this diagnosis is rarely, if ever, encountered. We present a rare case of a patient presenting to ED with worsening headaches over several months that developed acute-onset abdominal pain while being evaluated. Further workup showed free air, and the patient was taken emergently to the OR, where a perforated gastric ulcer was identified and biopsied. Pathology revealed gastric adenocarcinoma and subsequent MRI pointed to suspected LMC. Unfortunately, till today there is no effective treatment for advanced-stage gastric cancer, and aggressive intrathecal chemotherapy is only available to mitigate leptomeningeal involvement.

Developments in Postoperative Analgesia in Open and Minimally Invasive Thoracic Surgery Over the Past Decade.

Whether through minimally invasive or conventional open techniques, thoracic surgery is often reported to be one of the most painful surgical procedures due to the incision of intercostal and respiratory muscles, rib injury or resection, and placement of surgical drains. Some of the more severe complications related to poor analgesia include prolonged intensive care unit stay, mechanical ventilation, pneumonia, and the development of chronic postoperative pain syndromes. Over the past few decades, much progress has been made in recognizing the importance of multimodal analgesic techniques. These may include a variety of regional anesthetic techniques such as epidural anesthesia, fascial plane blocks, and intrapleural catheters, as well as the utilization of opioid and opioid-sparing oral regimens. This article provides an up-to-date review of pain management following thoracic surgery, emphasizing multimodal techniques and enhanced recovery pathways. In our review, we included articles published between 2010 and 2022. PubMed and Google Scholar were researched using the keywords thoracic, cardiac, pain control, thoracic epidural analgesia, fascial plane blocks, multimodal analgesia, and Enhanced Recovery after Surgery in thoracic surgery. Over 100 articles were then reviewed. We excluded articles not in English and articles that were not pertinent to cardiac or thoracic surgery. Eventually, 53 articles were included in the review, composed of clinical trials, case series, and retrospective cohort studies. A variety of pain control methods employed in thoracic and cardiac surgery range from opioids and opioid-sparing medications, such as acetaminophen and gabapentin, to regional techniques, such as fascial plane blocks to epidural anesthesia. Multimodal anesthesia combining regional and opioid-sparing analgesics and their combination in enhanced recovery protocols were shown to provide adequate pain control, decrease opioid consumption and lead to shorter lengths of stay. Postoperative pain control remains one of the biggest challenges in the care of thoracic surgery patients. Analgesic plans must be individualized for each patient. Multimodal analgesia remains the gold standard; however, more studies are still warranted. Finding the optimal combination of opioid and non-opioid pain medication and local anesthetic delivered via suitable regional technique will improve the outcomes and lead to successful patient recovery.

Toothpick: An Unusual Cause of Small Bowel Perforation in an Adult.

Foreign body ingestion is a common complaint in the pediatric population; however, in adults, this entity remains quite rare. Most cases are managed conservatively with serial examinations and imaging. Rarely, foreign body ingestion may cause small bowel perforation and peritonitis in adults. Perforation often warrants operative management, and assessment of bowel viability is crucial. Here, we present a case of foreign body ingestion requiring exploration, without the need for bowel resection or repair. Although the need for operative intervention in adults after foreign body ingestion remains rare, it is crucial to recognize those patients who are both at risk for foreign body ingestion and have underlying small bowel narrowing that puts them at risk for perforation. A high index of suspicion in these instances is mandatory as early recognition and appropriate treatment will improve outcomes.

Seasonality in General Surgery Hospitalizations and Procedures in the US: Workflow Implications.

INTRODUCTION: Seasonality has been studied in select conditions treated by surgeons and internists, but is not well understood regarding overall procedural volume in general surgery. Furthermore, much of the literature is limited due to lack of use of seasonal-trend-decomposition analyses. METHODS: All admissions with general surgery procedures were pooled from NIS 2002-2014, monthly hospitalization rates calculated, and seasonal-trend decomposition performed. RESULTS: Emergent admissions, accounting for 9% of the average annual incidence, had more prominent seasonality than elective admissions. Inpatient surgical-procedural volume remained relatively stable throughout the year and decreased only in the third quarter. Procedures for acute intra-abdominal conditions and traumas peaked in summer months, while endoscopies, tracheostomies and gastrostomies peaked in winter months. CONCLUSIONS: Many surgical pathologies and corresponding general-surgery procedures obey circannual patterns. Surgical workforce remains in high demand throughout the year except for fall and winter holidays. Understanding seasonal variation in such demand may be important for staffing and resource planning.

The Impact of Limited Language Proficiency in Screening for Breast Cancer.

BACKGROUND: The prevalence of a culturally diverse population in the United States continues to grow. Nevertheless, the national impact of limited English proficiency (LEP) in breast cancer screening is still unknown. METHODS: A retrospective review of the 2015 sample of the National Health Interview Survey database was performed. The cohort included women with and without LEP between 40 and 75 years. We evaluated differences in screening rates, baseline, socioeconomic, access to healthcare, and breast cancer risk factors with univariate and multivariate regression analyses. RESULTS: The prevalence of LEP was 5.7% (N = 1825, weighted counts 3936,081). LEP women showed a statistically significant lower rate of overall screening mammograms (78% vs. 90%), fewer benign lumps removed (6.4% vs. 17%) and lower rates of access to healthcare variables. They showed a higher rate of nonprivate insurance and living below the poverty line, a lower rate of hormone replacement therapy (1.8% vs. 5.6%), older menarche (12.97 vs. 12.75) and a higher rate of current menstruation (36% vs. 24). LEP women were associated with a lower probability of having a screening mammogram in multivariate analysis (OR: 0.67, 95% CI: 0.51-0.87). When LEP was subdivided into Spanish and "other" languages, Spanish speakers were associated with a lower probability of a screening mammogram (OR 0.67, 95% CI 0.49-0.90) while controlling for the same covariates. CONCLUSION: The results from our study showed that LEP women are associated with a lower probability of having a screening mammogram. Particularly, the Spanish speakers were found as a vulnerable subgroup.

Extensive Subcutaneous Emphysema Associated With Pneumothorax, Pneumomediastinum, and Pneumoperitoneum: A Case Report.

Subcutaneous emphysema (SE ) is a phenomenon in which air occupies structures under the skin and soft tissues. Common sites for SE include the neck and chest wall, which can extend to other body regions. In this case report, we describe the development of extensive SE, pneumothorax, pneumomediastinum, and pneumoperitoneum in an elderly female following blunt trauma to her right flank. The etiology of SE is broad and includes blunt and penetrating traumas; surgical, infectious, spontaneous causes; or any condition that yields a gradient between intra-alveolar and perivascular interstitial pressures. The incidence of SE has been reported to be 1.4%, while that of spontaneous pneumothorax has been reported to be 0.8% in patients receiving a percutaneous tracheostomy. Conversely, the occurrence of SE, pneumothorax, pneumomediastinum, and pneumoperitoneum in the same patient is rare. The most common signs and symptoms of SE are neck swelling and chest pain. Involvement of the deeper tissues of the thoracic outlet, chest, and abdominal wall often manifests in severe life-threatening conditions. SE can be diagnosed by detecting edema and crepitus of the scalp, neck, thorax, abdomen, and other body regions. Radiograph imaging can confirm the presence of soft-tissue air entry. Extensive SE in the setting of pneumothorax is an unusual entity for which there is, as of now, no consensus in management. Methods of treatment include supportive care, placement of blow holes for evacuation of soft-tissue emphysema, and bilateral infraclavicular incisions. SE is a rare complication that can arise from several etiologies. At the same time, various methods for managing this phenomenon have been mentioned with varying successful outcomes.

Management of a Bronchopleural Fistula After Right-Sided Lobectomy Using a Delayed Random Flap Under Guidance of Indocyanine Green (ICG) Angiography: A Case Report.

Bronchopleural fistula (BPF) following lung resection and thoracic surgery is associated with high rates of morbidity and mortality. Various methods are available for the closure of BPF and thoracic dead space, including flap procedures and thoracoplasty. While delayed random flaps have been used for the treatment of BPF and closure of thoracic dead space, no previous reports have described the concurrent use of laser-assisted indocyanine green angiography (ICG-A). We report a case of successful BPF closure with a random delayed fasciocutaneous flap using laser-assisted ICG-A guidance for flap delay.