Intravascular placement and migration of a colonic stent into the inferior mesenteric vein.

Colonic self-expanding metal stents (SEMSs) are commonly used to treat large bowel obstruction due to gastrointestinal malignancy with great success. While mortality is negligible, morbidity from both early and late complications can be significant. Stent perforation, erosion and migration are the most feared complications. We present the first reported case of wire-associated colon perforation with placement and migration of an SEMS into the inferior mesenteric vein (IMV). A man in his early 60s presented with a large bowel obstruction due to a colorectal mass. He underwent endoscopic colonic SEMS placement for colonic decompression. The stent was later found to be within the IMV, requiring a colon resection and retrieval of the stent.

Subclavian steal syndrome in a right aortic arch with aberrant left subclavian artery atresia.

Congenital aortic arch anomalies are an uncommon diagnosis resulting from embryologic malformations during the fourth to eighth week of gestation. Asymptomatic variants frequently are overlooked in the perinatal period and diagnosed incidentally during adulthood. Symptomatic variants can present with steal syndrome or dysphagia lusoria. The right aortic arch is a rare anomaly that is usually associated with other congenital anomalies but can occur in isolation. The most common types of right aortic arches are mirror image branching or an aberrant left subclavian artery. Aortic arch anomalies are important to recognize as they may have important implications in management. We present a 74-year-old female with a right aortic arch and aberrant left subclavian artery that was discovered after a fall. An extensive evaluation and work-up revealed symptoms consistent with subclavian steal syndrome that resolved following a carotid-axillary bypass. Subclavian steal secondary to a right aortic arch is extremely rare. This report reviews the current literature of a right aortic arch with an aberrant left subclavian artery presenting as a subclavian steal syndrome.

BET and Kelvin Analyses by Thermogravimetric Desorption.

Porous solids with nanometer-sized pores and large surface areas are a highly important class of materials. Uses of such materials include filtration, batteries, catalysts, and carbon sequestration. These porous solids are characterized by their surface areas, typically >100 m2/g, and pore size distributions. These parameters are typically measured using cryogenic physisorption, frequently referred to as Brunauer-Emmett-Teller (BET) analysis when BET theory is applied to interpret experimental results. Cryogenic physisorption and related analysis elucidate how a particular solid interacts with the cryogenic adsorbate, but this can be a poor predictor of how that solid will interact with other adsorbates, limiting the applicability of the results. Additionally, the cryogenic temperatures and deep vacuum required for cryogenic physisorption can cause kinetic limitations and experimental difficulties. This method nevertheless remains the standard technique to characterize porous materials for a wide variety of applications due to limited other options. In this work, a thermogravimetric desorption technique for determining surface areas and pore size distributions of porous solids available to adsorbates having boiling points above ambient temperature at ambient pressure is presented. A thermogravimetric analyzer (TGA) is used to measure temperature-dependent adsorbate mass loss, and isotherms are derived. For systems that exhibit multilayer formation, BET theory is applied to isotherms to derive specific surface areas. For systems that do not exhibit multilayer formation, the Kelvin equation is applied to determine pore size distributions and surface areas for the porous materials. In this study, the thermogravimetric method is applied to four adsorbents and two adsorbates─water and toluene─and results are compared to cryogenic physisorption results.

Congenital peritoneal encapsulation and superior mesenteric vein thrombosis: A case report.

Congenital peritoneal encapsulation is a rare entity characterized by an accessory peritoneal membrane that forms during embryonic development. Congenital peritoneal encapsulation is generally asymptomatic but can cause intermittent, colicky abdominal pain related to subacute small bowel obstruction. Diagnosis is made incidentally or upon surgical exploration for chronic abdominal complaints as preoperative imaging is typically nonspecific. We report a case of a 49-year-old male with epigastric abdominal pain, constipation, and superior mesenteric vein thrombosis on imaging. Upon exploratory laparotomy, the small bowel was covered by an accessory peritoneal sac consistent with congenital peritoneal encapsulation. The accessory sac was excised completely, and the patient recovered well. Although rarely causing significant gastrointestinal symptoms, congenital peritoneal encapsulation is an anomaly that requires surgical intervention.

Abnormal presentation of ascending cholangitis.

Ventriculo-peritoneal, -gallbladder, -pleural, -atrial, and -jugular shunts are all viable options in the treatment of hydrocephalus 1, 2, 3. Retrieval of these catheters can often be very difficult and may be unsuccessful or incomplete. Retained catheters can result in unforeseen and unexpected complications.

Beware of the interval cholecystectomy.

BACKGROUND: Despite limited data regarding the indications and effectiveness of percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis (AC), usage has increased by over 500% since 1994. Many of these patients subsequently undergo interval cholecystectomy (IC), a procedure that has not been rigorously evaluated. This aim of this study was to quantify the morbidity and mortality associated with the IC. METHODS: We included all consecutive adult patients (>18 years old) who underwent PC and IC from January 2008 to December 2013. Conversion rate, length of operation, biliary injury, estimated blood loss, surgical site infection, length of stay, and mortality were compared with 227 patients who underwent cholecystectomy for AC during the same time interval. RESULTS: Of 18,501 patients who underwent cholecystectomy, 337 had at least one PC and 177 underwent subsequent IC. Compared with patients undergoing cholecystectomy for clinically diagnosed AC, patients undergoing IC were older (69.8 vs. 54.9 years; p < 0.001), thinner (body mass index, 28.7 vs. 31.1; p = 0.002), more complex by Tokyo grade (1.9 vs. 1.1; p < 0.001), and American Society of Anesthesia classification (3.0 vs. 2.5; p < 0.001), had longer operative times (120.7 vs. 92.5 minutes; p < 0.0001), more blood loss (30 vs. 15 mL; p = 0.01), and increased rates of conversion (26.6% vs. 12.8%; p < 0.001), surgical site infection (12.4% vs. 0.4%; p < 0.001), bowel injury (6.2% vs. 0.4%; p < 0.001), and 1-year mortality (15.3% vs. 0.4%; p < 0.01). Nonsignificant trends included significant biliary tract injury (3 vs. 0; p = 0.08) and longer length of stay (7.3 vs. 4.8 days; p = 0.39). Linear regression identified body mass index (p = 0.03), time from admission to PC (p = 0.03), and American Society of Anesthesia classification (p = 0.06) as predictors of a difficult IC. CONCLUSION: PC has been widely adopted with limited description of the subsequent IC. Our data detail the factors predicting the challenges of IC and document that it is a difficult operation associated with significant morbidity. LEVEL OF EVIDENCE: Therapeutic, level IV.

Dabigatran etixilate and traumatic brain injury: Evolving anticoagulants require evolving care plans.

AIM: To investigate the outcomes of trauma patients with traumatic brain injury (TBI) on Dabigatran Etexilate (DE). METHODS: Following IRB approval, all patients taking DE who were admitted to our level 1 trauma service were enrolled in the study. Injury complexity, length of stay (LOS), intensive care length of stay, operative intervention, therapeutic interventions and outcomes were analyzed retrospectively. RESULTS: Twenty-eight of 4310 admissions were taking DE. Eleven patients were excluded on concurrent antiplatelet therapy. Average age was 77.14 years (64-94 years), and average LOS was 4.7 d (1-35 d). Thirty-two percent were admitted with intracranial hemorrhage. Eighteen percent received factor VII, and 22% received dialysis in attempts to correct coagulopathy. Mortality was 21%. CONCLUSION: The low incidence, absence of reversal agents, and lack of practice guidelines makes managing patients with TBI taking DE frustrating and provider specific. Local practice guidelines may be helpful in managing such patients.

Radiographic assessment of ground-level falls in elderly patients: Is the "PAN-SCAN" overdoing it?

INTRODUCTION: Routine, whole-body computed tomography imaging (PAN-SCAN) has been shown to identify unexpected injuries and alter the management of patients presenting with blunt trauma. We sought to characterize the changes in practice over time and the utility of PAN-SCAN imaging in elderly patients who fall and require admission to a trauma center. METHODS: We performed a retrospective analysis by using data derived from a Pennsylvania state-wide trauma registry (2007-2010). All hemodynamically stable patients (>65 years) who had a ground-level fall and were admitted for >24 hours were selected. Patients who underwent a combination of all three scans within 2 hours of arrival were considered to have underwent PAN-SCAN imaging. Clinical outcomes were compared across PAN-SCAN patients relative to less diagnostic imaging. Regression analysis was used to determine whether PAN-SCAN imaging was an independent determinate of mortality and resource use. RESULTS: Over the period of study, 13,043 patients met inclusion criteria. The annual rate of PAN-SCAN imaging after ground-level falls increased over time. After we controlled for important confounders, PAN-SCAN imaging was not associated with mortality (odds ratio 0.97, P = .74, 95% confidence interval 0.80-1.18). Despite greater injury severity, PAN-SCAN imaging was independently associated with significantly lesser intensive care unit requirements, step-down days, and a lesser overall duration of stay. CONCLUSION: PAN-SCAN imaging has become more common over time in elderly patients having a ground-level fall. Although PAN-SCAN imaging during the initial trauma evaluation was not associated with an independent decrease in the risk of mortality, it was independently associated with lesser hospital resource use. These data suggest that whole-body computed tomography imaging may benefit trauma center resource use for patients with ground-level falls.

The unacknowledged incidence of laparoscopic stapler malfunction.

BACKGROUND: Laparoscopic instruments are being used with increasing frequency. Our surgeons recently experienced several independent adverse events involving the laparoscopic linear stapler. Although the Food and Drug Administration maintains a Manufacturer and User Facility Device Experience (MAUDE) database to track such voluntary reports, many events are not reported and the true incidence of adverse events is unknown. We attempted to determine how frequently minimally invasive surgeons have experienced technical problems with a laparoscopic stapler. METHODS: Following IRB approval, we electronically distributed an anonymous 10-question survey to the 124 minimally invasive program directors listed in the Fellowship Council database. The questions focused on personal or peer experience with laparoscopic stapler malfunction, frequency and type of malfunction, device manufacturer, whether the operation was altered, and root cause analysis of the event. RESULTS: Forty-four of the 124 program directors (35%) completed the survey. The majority reported personal or peer experience (86%) with a linear stapler not releasing (66%) or not firing (73%) after application, with 27% of the respondents noting that this occurred three or more times. The malfunction was not related to type of load, straight (23%) or reticulating (32%) model, or manufacturer (Ethicon 30%, Covidien 36%). One quarter of the respondents noted that the malfunction caused them to significantly alter their operative procedure, and 30% reported that they received no helpful feedback from the manufacturer despite contacting it. CONCLUSIONS: Most minimally invasive surgeons have experienced laparoscopic linear stapler malfunction and 25% have had to significantly alter the planned operative procedure due to the malfunction.

Evolving role of endovascular techniques for traumatic vascular injury: a changing landscape?

BACKGROUND: Endovascular management of blunt aortic injury has dramatically reduced the morbidity and mortality associated with this specific injury. There remains a paucity of evidence quantifying the beneficial effects associated with endovascular (ENDO) techniques for other vascular injury types and little information regarding the impact ENDO techniques have had on the management of traumatic vascular injuries over time. METHODS: We performed a retrospective analysis of data from the National Trauma Data Bank over 2002 to 2006 and 2008 time periods (NTDB 7.2 and RDS 2008). Injured patients undergoing any arterial vascular repair procedure using ENDO or standard open techniques were determined using ICD-9-CM procedure codes. Abbreviated Injury codes were used to select patients who suffered subclavian, carotid, or thoracic aortic injury. Logistic regression was used to determine whether EARLY ENDO procedures (first 24 hours after injury) were independently associated with a lower risk of mortality. RESULTS: The percentage of ENDO procedures significantly increased over time irrespective of mechanism of injury. When aortic (thoracic), subclavian, and carotid arterial injuries were analyzed, a significant decrease in mortality over time was found. The percentage of ENDO procedures for all arterial injury subtypes significantly increased in the RECENT (2008) period. Seventy-five percentage of ENDO procedures occurred early (initial 24 hours) with 20% of those patients being hypotensive upon arrival (systolic blood pressure <90 mm Hg). For patients who had vascular procedures in the RECENT period, regression analysis revealed that early ENDO procedures were independently associated with a 35% reduction in mortality risk (odds ratio, 0.65; 95% confidence interval, 0.5-0.8) after controlling for major confounders including mechanism of injury and presence of hypotension on arrival. CONCLUSION: ENDO procedures for arterial injury have increased over time while mortality for arterial injury subtypes has significantly decreased. Early ENDO procedures are common and are independently associated with a lower risk of mortality. These results suggest outcomes after vascular injury may benefit from ENDO expertise and that ENDO techniques should be incorporated into the early treatment algorithm of trauma patients with vascular injury, particularly those that require difficult operative exposure.

Abdominal aortic pseudoaneurysm managed with endovascular stent graft.

Angioplasty, stenting, endovascular stent grafts, and other minimally interventional techniques are becoming common techniques used for a myriad of vascular pathology. As the technology, comfort level, and technical expertise improve, the envelope of overuse is being approached or possibly superceded. We present an unusual complication of pancreatitis, pseudoaneurysm of the abdominal aorta, which was successfully treated with an endovascular stent graft.

Intracystic Papillary Carcinoma of the Breast.

We present the case of a 63-year-old woman with intracystic papillary carcinoma of the breast who presented with a palpable mass, one year after a negative mammogram. Sonography showed a complex mass and ultrasound-guided aspiration cytology was negative, and the patient returned 6 months later with a recurrent mass. Excisional biopsy revealed invasive intracystic papillary carcinoma. Intracystic papillary carcinoma is a rare malignancy of the breast primarily affecting postmenopausal women. As opposed to invasive micropapillary carcinoma, intracystic papillary carcinoma is a low-grade carcinoma with a favorable prognosis.

What do physician extenders in a general surgery residency really do?

OBJECTIVE: The 80-hour workweek has forced surgical training programs to employ physician extenders to reduce work hours and improve the educational environment. The purpose of our study was to document objectively the specific workload provided by physician extenders and to evaluate any objective or subjective benefit provided to the residency program. METHOD: Over 4 consecutive months, all orders written by 2 physician extenders associated exclusively with the general surgery residency program at our institution were reviewed. They were categorized as daytime or evening orders and were subdivided into admission, routine preoperative and postoperative, acute care, daily laboratories, pain medications, Pro re nata (PRN), wound care, and discharge orders. Acute care issues and PRN orders were individually examined and subdivided. The appropriateness, total volume, and the orders for each category were totaled and reviewed. RESULTS: Overall, 3101 total orders (1128 daytime and 1973 nighttime) were reviewed in a 4-month time period. On average, physician extenders at night wrote 35 orders per shift, compared with only 18.8 orders during the day. During the night, admission orders totaled 547 (27.7%), preoperative orders 442 (22%), acute care issues 324 (16.4%), PRN orders 239 (12%), and pain medication and PRN sleeping pills 156 (8%). During the day, routine postoperative orders totaled 305 (27%), daily laboratories 184 (16%), and discharge orders 253 (22%). CONCLUSION: Physician extenders wrote appropriate orders and reduced resident workload. Educational opportunities increased because fewer residents left conference for acute patient care issues, and 1 fewer resident was absent during the day secondary to 1 less resident being sent home postcall. Performance on the American Board of Surgery In-Training Examination (ABSITE) increased dramatically for a focused group of residents. As the expense of each extender is approximately $90,000, justification to administration is dependent on the institutional support and efficiency of the residency program. A clear simple outcome is that by improving standing orders and clinical pathways, and by using an electronic medical record system, noneducational work hours can be reduced significantly.

Laparoscopic management of a small bowel obstruction of unknown cause.

With the expanding indications for minimally invasive surgery, the management of small bowel obstruction is evolving. The laparoscope shortens hospital stay, hastens recovery, and reduces morbidity, such as wound infection and incisional hernia associated with open surgery. However, many surgeons are reluctant to attempt laparoscopy in patients with significantly distended small bowel and a history of multiple previous abdominal operations. We present the management of a patient with a virgin abdomen who presented with a small bowel obstruction most likely secondary to Fitz-Hugh-Curtis syndrome who was successfully managed with laparoscopic lysis of adhesions.

Is acute appendicitis a surgical emergency?

Urgent appendectomy has become the basis of management for acute appendicitis because of the disparity in morbidity and mortality rates between perforated and nonperforated appendicitis. Immediate surgery results in the confirmation of diagnosis and the control of sepsis without the risk of recurrent appendicitis. However, when notified by the emergency room of the diagnosis, many surgeons are opting to begin antibiotics and intravenous fluids and to schedule the appendectomy at their convenience. We hypothesize that using intravenous antibiotics and hydration to delay appendectomy until "normal business hours" has a negative impact on patient morbidity and mortality. During a 23-month period, the medical records of 81 patients at a single institution who underwent appendectomy were reviewed. All patients had preoperative CT scans and all operations were performed by one of two surgeons. Group A included those patients who underwent appendectomy within 10 hours of CT diagnosis and group B included those appendectomies performed greater than 10 hours after diagnosis. Wound complications, antibiotic use, total analgesic requirements, length of operation, and hospital length of stay were used for comparison. The average time to operation (3.18 vs 15.85 hours), operative time (54.1 vs 55.7 minutes), length of stay (2.65 vs 2.09 days), wound infections (4 vs 0), and antibiotic use at discharge (19 vs 3) for group A and B were not statistically different. This data suggests that delaying operative intervention for acute appendicitis to accommodate a surgeon's preference or to maximize a hospital's efficiency does not pose a significant risk to the patient.

Carotid artery fibromuscular dysplasia.

Extracranial carotid artery fibromuscular dysplasia (FMD) is a rare finding that is frequently incidental and asymptomatic. It usually occurs in middle-age women and is secondary to medial fibrodysplasia or, less commonly, intimal fibrodysplasia. The carotid artery may be elongated or kinked and associated aneurysms have been reported. Symptoms including transient ischemic attack or stroke are uncommon and are due to low flow or embolization of platelet aggregates. Digital subtraction angiography demonstrates high-grade stenosis with the characteristic "string of beads" pattern. Antiplatelet medication with sequential imaging is the accepted therapy for asymptomatic lesions. Graduated endoluminal dilation under direct vision should be reserved for patients with documented lateralizing symptoms.