Intestinal Aspergillosis: Systematic Review on Patterns of Clinical Presentation and Management.

Background: Intestinal aspergillosis (IA) is a rare entity primarily discovered in immunocompromised patients. Because of its low incidence, IA is not considered routinely in the differential of abdominal pain, distension, and diarrhea. A systematic characterization of demographics, comorbidities, clinical presentations, and outcomes can help surgeons recognize and manage IA in critically ill patients. Methods: Two independent authors carried out the literature search using PubMed, MEDLINE, and Scopus databases. The Mesh terms utilized were: 'intestinal' and 'aspergillosis' combined with the Boolean operator 'AND' (synonyms were combined with the Boolean operator 'OR'). Intestinal aspergillosis was defined as inflammation of the gastrointestinal tract (duodenum to rectum) caused by Aspergillus spp. All articles reporting IA were included. Articles describing aspergillosis of the esophagus or stomach were excluded. Statistical analysis was performed using SPSS software (version 18; SPSS Inc., Chicago, IL). Results: Forty-two articles reporting 56 cases were included in the study. Mean age was 44.9 ± 20.5 years. Male to female ratio was 29:27. The most common condition in patients who developed IA was transplantation (19 patients; 34%). The most common clinical presentations of IA were abdominal pain (21 patients; 38%) and diarrhea 12 patients; 21%). Sixty-six percent of patients had primary IA whereas 34% developed IA secondarily to systemic infection. Diagnostic modalities included exploratory laparotomy (35 patients; 63%) and endoscopy (7 patients; 13%). Mean time to diagnosis was 8.6 ± 11.3 days. Intestinal aspergillosis was limited to the small bowel in 61% of patients. In 43 (77%) patients, bowel resection is the definitive treatment, whereas 13 (23%) patients underwent antifungal therapy alone. Mortality rate was 39%. Sixty-three percent of patients treated with surgery survived, compared with 46% treated with antifungal therapy alone (p = 0.34). Conclusion: Intestinal aspergillosis is a life-threatening condition with a mortality rate of 39%. Extrapulmonary IA is seen in patients with neutropenia, sepsis, inflammatory conditions, and immunosuppression. Patients who undergo surgery are more likely to survive this infection.

Does the adoption of an emergency general surgery service model influence volume of cholecystectomies at a tertiary care center.

INTRODUCTION: The purpose of this study was to evaluate the rate of cholecystectomy before and after adoption of an emergency general surgery (EGS) model at our institution. METHODS: A longitudinal, observational study was conducted prior to and following introduction of an EGS model at our institution. Using the New York SPARCS Administrative Database, all adult patients presenting to the emergency department with gallbladder-related emergencies were identified. The rates of laparoscopic and open cholecystectomies performed 3 years prior and 3 years following the adoption of the EGS model were examined. A multivariable logistic regression model was used to compare the incidence of cholecystectomy at initial ED visit at our institution pre- and post-EGS introduction as well as to those in the rest of the state as an external control group, while adjusting for potentially confounding factors. RESULTS: There were 176,159 total ED visits of patients with gallbladder emergencies (154,743 excluding repeat presenters) in the studied period in NY State. Of these, 63,912 patients (41.3%) had a concurrent cholecystectomy in NY State. The rate of cholecystectomy at these institutions remained relatively steady from 38.8% from 2010 to 2013 and 38.6% from 2013 to 2016. At our institution, there were 2039 gallbladder emergencies, and of those 755 underwent cholecystectomy. At our institution, there was an increase from 28.21% 3 years prior to the adoption of the EGS model to 40.2% in the following 3 years (RR = 1.06, 95% CI 1.0164-1.1078, p = 0.0069). CONCLUSION: The initiation of the EGS model at a tertiary center was associated with a significant increase in the number of concurrent cholecystectomies from 28.21 to 40.2% over a 6-year period. This change was accompanied by an increase in the number of patient comorbidities and a lower insurance status.

Surveillance of moderate-size aneurysms of the thoracic aorta.

BACKGROUND: There are no evidence based guidelines for the surveillance of patients with moderate-sized (<5 cm) thoracic aortic aneurysms (MTAA), who do not warrant surgical intervention. The purpose of this study was to review the MTAA patient surveillance strategy used currently at the Northport Veterans Affairs Medical Center, to assess outcomes over time and accrue data to develop guidelines to optimize MTAA patients' follow-up. METHODS: The study group included veterans referred to the Thoracic Surgery clinic for the management of moderate-sized (<5 cm) thoracic aortic aneurysms (MTAA) not warranting immediate surgical repair. As a pilot study, all MTAA patients' charts from 2005-2013 were reviewed to describe imaging practices and evaluate patient-specific long-term outcomes. An adverse composite endpoint was defined if a patient's aneurysm grew substantially (≥0.5 cm/year or reached 5.5 cm) or a MTAA-related event (surgery or death) occurred. Additionally, number of CT scans obtained during the follow up period were documented. RESULTS: For 110 MTAA patients, the average presenting index size was 4.45 ± 0.4 cm with average growth of 0.04 cm total (0.03 cm/year). Fourteen (13%) patients met the adverse composite endpoint, with no MTAA-related deaths. Patients achieving the adverse composite endpoint had higher index sizes (4.81 vs. 4.40 cm, p = 0.001) and higher average growth rates as compared to non-endpoint patients (0.16 vs. 0.01 cm, p = 0.0009). Optimizing the negative likelihood ratio defined a new "not-at-risk" population with aneurysm index size < 4.3 cm. A shorter time to adverse event for "at-risk" patients was found versus "not-at-risk" patients (p = 0.02). On average, there were 4.8 CT scans/patient and estimated cumulative radiation dose of 34 mSv/patient. Only one "not-at-risk" patient had substantive MTAA growth (≥0.5 cm/year) over the 8 year follow-up period. CONCLUSION AND RELEVANCE: Annual imaging of MTAA "not-at-risk" patients appears unwarranted, resulting in potentially excessive radiation exposure. Although additional research is necessary for validation, longer surveillance imaging intervals (beyond one year) seem appropriate for MTAA patients presenting with < 4.3 cm index aneurysms.