Surgical Management of Complicated Thoracic Fungal Infections: A Case Series from a Tertiary Referral Center.

Although rare in the general population, pulmonary fungal infections usually occur in immunocompromised patients. The mainstay of pulmonary fungal infection treatment is prolonged intravenous antifungal therapy. However, surgical management may be required in cases of complex disease, resistance to medical therapy or percutaneous procedures, or associated complications such as fungal empyema and massive hemoptysis. In this series, we present three patients with complicated thoracic fungal infections who underwent individualized surgical management over a 3-month period in 2022 at our institution. Complicated pulmonary fungal infections require surgical intervention to ensure complete resolution. The choice of operation is dependent on several factors, and surgeons operating on these patients must be privy to the various surgical modalities that may be required to successfully treat these patients.

The intra-abdominal zebra, paraduodenal hernias resulting in small bowel obstructions: a case series.

Paraduodenal hernias are a rare but important clinical entity, as their presentation can be life-threatening if not properly diagnosed and managed appropriately. Additionally, this entity is defined by a unique and complex congenital anatomical abnormality which dictates a specific treatment algorithm. Here we present the cases of three patients from our clinical experience who all presented with either acute or chronic small bowel obstructions secondary to paraduodenal hernias. Two were left-sided paraduoenal hernias and one was right-sided. All three patients were successfully managed with surgical intervention. An appreciation of paraduodenal hernias, including the defining anatomy and methods of surgical management, is important for the general surgeon.

Impact of Live Tissue Training on Provider Confidence for Operative Trauma Management.

INTRODUCTION: Readiness of military health care providers is essential to maintain a prepared fighting force and remains a central issue for today's military. Maintaining skills regarding operative management of trauma is becoming more difficult if not located at an urban trauma center. Live tissue training may be used to practice skills in a facility that does not have exposure to high acuity trauma. The goal of our live tissue skills course is to train health care providers and ancillary staff in the management of various injury complexes and improve confidence and familiarity with management using a porcine model. MATERIALS AND METHODS: A live tissue skills course using a porcine model was offered to surgical residents, attendings, and operating room technicians. Before completing the course, each participant completed a survey assessing comfort level, previous training experiences, and deployments. Operative management was simulated with a standardized sequence of abdominal and thoracic injuries. After the course, each participant then completed a survey assessing comfort level, benefit of the course, and comparison to inanimate simulation training. Survey information was obtained via participant completion of a multiple-choice confidential questionnaire. RESULTS: Responses were collected from 34 participants at our institution. Average abdominal trauma comfort increased from 2.79 to 3.73, with no participants reporting feeling not comfortable at all post-lab. Average thoracic trauma comfort increased from 2.47 to 3.48, with one participant reporting feeling not comfortable at all post-lab. Overall, 85% of participants reported the course to be very beneficial in improving their knowledge, 83% reported the course to be very beneficial compared to inanimate simulators, and 92% reported high fidelity of the live tissue training course. CONCLUSIONS: Perceived as highly beneficial, live tissue training increased comfort with operative trauma management by surgical residents, attendings, and technicians supporting continued utilization. Further evaluation of live tissue courses would be advantageous in assessing surgical skill improvement, including comparison with simulation training.

Practice Patterns of Pancreatic Surgery Within the Military.

INTRODUCTION: Pancreatic surgery is technically challenging, with mortality rates at high-volume centers ranging from 0% to 5%. An inverse relationship between surgeon volume and perioperative mortality has been reported suggesting that patients benefit from experienced surgeons at high-volume centers. There is little published on the volume of pancreatic surgeries performed in military treatment facilities (MTF) and there is no centralization policy regarding pancreatic surgery. This study evaluates pancreatic procedures at MTFs. We hypothesize that a small group of MTFs perform most pancreatic procedures, including more complex pancreatic surgeries. METHODS: This is a retrospective review of de-identified data from MHS Mart (M2) from 2014 to 2020. The database contains patient data from all Defense Health Agency treatment facilities. Variables collected include number and types of pancreatic procedures performed and patient demographics. The primary endpoint was the number and type of surgery for each MTF. RESULTS: Twenty-six MTFs performed pancreatic surgeries from 2014 to 2020. There was a significant decrease in the number of cases from 2014 to 2020. Nine hospitals performed one surgery over eight years. The most common surgery was a distal pancreatectomy, followed by a pancreaticoduodenectomy. There was a decrease in the number of pancreaticoduodenectomies and distal pancreatectomies performed over this period. CONCLUSIONS: Pancreatic surgery is being performed at few MTFs with a downward trajectory over time. Further studies would be needed to assess the impact on patient care regarding postoperative complications, barriers to timely patient care, and impact on readiness of military surgeons.