Appendectomy or not in middle-aged male with non-inflamed appendix in Amyand's hernia? Case report and literature review.

INTRODUCTION: An Amyand's hernia is a rare disease where a vermiform appendix is found within an inguinal hernia sac. It is reported in the literature as having an incidence between 0.4%-1.0% of reported hernia cases. Typically, an incidental finding, Amyand's hernia is consequently found more frequently intra-operatively rather than preoperatively. PRESENTATION OF CASE: This case is a recount of a 56-year-old male, who presented in an outpatient setting for the evaluation of right inguinal pain and bulge. The patient was diagnosed with a vermiform appendix within the indirect hernia. The patient underwent elective repair of his inguinal hernia via Transabdominal Preperitoneal (TAPP) approach of the hernia with avoidance of appendectomy. DISCUSSION: An Amyand's hernia presents a challenging diagnosis and the treatment algorithm is contingent on the condition of the appendix in individual cases. This case presents a Type 1 Amyand's hernia that was repaired through laparoscopic approach using prosthetic mesh. The aim of this case study highlights the approach to surgical decision making in the diagnosis and treatment of Amyand's hernia proposed in the current literature. CONCLUSION: This case presents a rare condition known as Amyand's hernia followed by a discussion on the epidemiology, diagnostic workup, and treatment options. Treatment is dependent on the state of the appendix found in the hernia sac and the clinical scenario. Comprehensive literature review shows that the true prevalence of this disease is lower than classically described and still has no clear standardized approaches.

Does sacrifice of the inferior mesenteric artery or superior rectal artery affect anastomotic leak following sigmoidectomy for diverticulitis? a retrospective review.

BACKGROUND: Anastomotic leak after sigmoidectomy for diverticular disease can have devastating consequences. Preservation or sacrifice of the descending colon or rectal arterial supply may affect the anastomosis. The aim of this study was to evaluate whether preservation of the inferior mesenteric artery (IMA) or superior rectal artery (SRA) was associated with a decreased anastomotic leak rate. METHODS: A retrospective review of adult patients undergoing sigmoidectomies from 2 military tertiary care centers was performed, evaluating patient demographic and operative variables for their effects on anastomotic leak rate. RESULTS: A total of 130 patients were identified. The overall anastomotic leak rate was 5.4%. Laparoscopy was used in 41%, and stapled anastomoses were used in 91%. The IMA was sacrificed in 29% and the SRA in 37%. There were no significant differences in leak rates when the IMA or SRA was sacrificed (0% and 3.7% with the IMA and SRA sacrificed, 9.3% and 6.5% with the vessels preserved; P = .140 and P = .610, respectively). Laparoscopic technique (P = .843), emergency surgery (P = .29), and operative time (P = .78) did not affect leak rate. Hand-sewn anastomoses were associated with a higher leak rate (33% vs 2%; odds ratio, 3.44; 95% confidence interval, 1.514-7.817; P < .001). CONCLUSIONS: IMA or SRA preservation or sacrifice was not associated with an increased leak rate from colorectal anastomoses after sigmoidectomy for diverticular disease. Stapled anastomoses were associated with a lower leak rate than hand-sewn anastomoses.

Hypoxemic versus normoxemic reperfusion in a large animal model of severe ischemia-reperfusion injury.

BACKGROUND: Prior studies have suggested a significant benefit of using deliberate hypoxemia to reperfuse ischemic tissue beds, primarily by reducing free radical injury. We sought to examine the effects of a hypoxemic reperfusion strategy in a large animal model of severe truncal ischemia. MATERIALS AND METHODS: Adult swine were subjected to 30 min of supraceliac aortic occlusion and randomized to two groups: normoxemia group (n = 9), with resuscitation at a pO2 >100 mmHg or hypoxemia group (n = 10), with initial resuscitation at a pO2 of 30-50. The two groups were compared using physiologic parameters, fluid and pressor requirements, inflammatory and oxidative markers, and histologic analysis of end-organ injury. RESULTS: All animals developed significant hemodynamic instability immediately upon reperfusion. Average mean arterial pressure at baseline rose significantly after 30 min of cross-clamp (76.8 versus 166.3 mmHg, P < 0.001). Upon reperfusion, all animals required epinephrine and fluids to maintain mean arterial pressure (MAP) greater than 60 mmHg. After stabilization, the two groups were similar in terms of central and pulmonary hemodynamics. The hypoxemic group required more mean total epinephrine (18.35 mg versus 5.28 mg, P < 0.01) with no significant difference in total fluid volume (hypoxemic 9111 ml versus 8420 mL, P = 0.730). The hypoxemic group demonstrated a more severe metabolic acidosis at all time intervals after reperfusion (pH 7.02 versus 7.16 and lactate 17 versus 13, both P < 0.01). There was no difference in malondialdehyde concentration between the two groups, but the hypoxemic group had a higher antioxidant reductive capacity at all intervals after 30 min of reperfusion (0.23 versus 0.27 uM, P = 0.03). While there was significant end-organ damage on pathologic examination of all liver and kidney specimens (mean severity of injury 1.59 and 1.76, respectively, on a scale of 1-3), there was no significant difference between the two groups. CONCLUSIONS: A hypoxemic reperfusion strategy in this large animal model failed to demonstrate any significant clinical benefit. Although there was chemical evidence of improved antioxidant capacity with hypoxemia, it was associated with more instability, metabolic and physiologic derangements, and no evidence of end-organ protection.

Vascular surgery knowledge and exposure obtained during medical school and the potential impact on career decisions.

BACKGROUND: The pathway to primary certification in vascular surgery is evolving, requiring trainees to make earlier career decisions. The goal of this study was to evaluate exposure to and knowledge of vascular surgery obtained during medical school that could affect career decisions. METHODS: A survey was conducted of recent medical school graduates entering military residency programs. Questions were designed to ascertain the medical school attended and degree obtained, exposure to and perception of vascular surgery, and basic vascular surgery knowledge. RESULTS: Of 316 individuals who were identified and sent surveys, 218 (69%) responded. There were 131 allopathic graduates (60%), 87 (40%) osteopathic graduates, and 53 (25%) were entering a surgical residency. Clinical clerkships (32%) were the primary reason for specialty selection, followed by lifestyle (29%). Most respondents (66%) did not have a vascular clinical clerkship. Regarding perception, 56% of respondents would consult interventional radiology for a peripheral arteriogram vs vascular surgery (39%). The mean score of the knowledge-based questions was 69%. Incoming postgraduate year (PGY) 1 surgical residents had a statistically higher mean score on the knowledge portion (P < .001). In addition, a positive correlation was noted with the number of weeks spent on a surgical (P < .03) and a vascular surgical (P < .001) rotation and the mean score. Subgroup analysis revealed a higher percentage of individuals with a vascular clerkship achieved a "high" score vs those without a vascular surgery clerkship (P < .001). CONCLUSION: Our cohort of medical school graduates had limited exposure to and knowledge of vascular surgery. Providing more clinical exposure in medical school appears necessary to ensure success of the modified pathways for primary certification in vascular surgery.

A simplified set of trauma triage criteria to safely reduce overtriage: a prospective study.

BACKGROUND: Many trauma systems have adopted complex triage algorithms that are difficult to use and contain poorly validated variables. OBJECTIVE: To prospectively evaluate the performance of our institution's current triage system compared with a simplified system using only 4 highly predictive variables. DESIGN, SETTING, AND PATIENTS: A prospective observational study of trauma patients in a 9-month period at an academic level II trauma center was undertaken. All trauma admissions were analyzed for the need for immediate emergency interventions or operative procedures. The accuracy and safety of the current triage system was compared with a simplified triage protocol using only 4 variables (hypotension, mental status, altered respirations, and penetrating truncal wound). Overtriage and undertriage rates were compared, and detailed analysis of all undertriaged patients was performed. MAIN OUTCOME MEASURES: Rates of overtriage, undertriage, morbidity, and mortality. RESULTS: There were 244 trauma team activations, with 21% requiring urgent intervention. Existing criteria produced an overtriage rate of 79%, an undertriage rate of 1%, and mistriage in 14%. Using the simplified criteria, the overtriage rate was reduced to 12% and the undertriage rate was increased to 4% (both P < .05). Undertriaged patients were all hemodynamically stable, with 4 requiring tube thoracostomy only and 4 undergoing nonemergent laparotomy (2 nontherapeutic laparotomies, 1 bladder repair, and 1 bowel mesenteric injury). There were no deaths among undertriaged patients with either system. CONCLUSIONS: Using a simplified triage system can safely reduce the rate of overtriage. This could conserve resources, reduce mistriage from misunderstood guidelines, and improve specificity by including only those variables with high predictive value.

Resectional gastric bypass outcomes in active duty soldiers: a retrospective review.

BACKGROUND: As in civilian life, some active duty service members have developed severe obesity that is refractory to diet alteration and exercise. In addition to controlling obesity, surgical weight control measures in an active duty population must consider the effect of the postbariatric state on a service member's ability to continue to be deployable to a war zone or other austere military assignment. We report our experience with such patients undergoing open resectional gastric bypass. METHODS: We retrospectively reviewed the perioperative and long-term outcomes of 33 active duty service members who had undergone open gastric bypass by the same surgical team at a single institution during a 30-month period. Data were collected by chart review and questionnaires. Descriptive and inferential analyses were performed using Statistical Package for Social Sciences, version 14.0. RESULTS: The questionnaires were returned by 27 patients (13 women and 14 men). The mean age at surgery was 34.2 years (range 24-51). The mean follow-up was 218 weeks (range 162-369). The mean preoperative body mass index was 40.6 kg/m(2) (range 34.0-49.4). The mean postoperative BMI was 25.6 kg/m(2) (range 19-34.7). Using the Bariatric Analysis and Reporting Outcome System outcome criteria for these 27 patients, the results were fair for 4 patients (15%), good for 9 (33%), very good for 12 (44%), and excellent for 2 (7%). No patients had treatment failure according to the Bariatric Analysis and Reporting Outcome System criteria. Also, 5 patients who had previously been nonpromotable because of their weight were reclassified as promotable after the results of the bariatric intervention. Of the 27 patients, all but 3 maintained or achieved deployable status after surgical recovery. CONCLUSION: As in civilian populations, bariatric surgery improves the quality of life of active duty service members who have failed nonoperative means of obesity control. Most service members who undergo bariatric intervention are able to successfully deploy to war zones without adverse effects on their military performance and retain or improve their competitiveness for career promotion.

Natural course and outcome of cystic lesions in the pancreas.

BACKGROUND: The number of patients identified with cysts of the pancreas is increasing. The current study was undertaken to assess the natural course and malignant potential of pancreatic cysts. METHODS: From 1995 to 2008, radiology records were reviewed for the presence of cystic lesions of the pancreas (CLP) characteristics, patient demographics, and follow-up. RESULTS: Eighty-two patients met the study inclusion criteria, with a mean age at time of diagnosis of 64.4 +/- 16.7 years. Mean cyst size was 1.36 +/- 1.05 cm, with 75.6% of patients having a solitary cyst. Thirteen patients underwent surgery. Operative intervention was statistically related to symptomatic, loculated cysts with the presence of calcifications (all P <.05). Malignancy was statistically related to symptomatic (P <.05), loculated cysts (P <.01), and male gender (P <.05). CONCLUSIONS: Our data show that most pancreatic cysts found on radiographic imaging are asymptomatic, solitary, and small and can be followed safely radiographically.

Improved rates of colorectal cancer screening in an equal access population.

BACKGROUND: National colorectal cancer (CRC) screening averages 50% to 60%. We aimed to identify screening prevalence in select Department of Defense (DOD) beneficiaries with equal access to care. METHODS: December 2007 cross-sectional data of patients over 50 years of age included patient demographics, screening modality, and compliance. RESULTS: Of 17,252 patients (52% male; mean age 63.2 +/- 8.1 years), 12,229 (71%) were up-to-date with national screening guidelines. Modalities included colonoscopy (83.0%), flexible sigmoidoscopy with fecal occult blood testing (FOBT) (32.2%), and air-contrast barium enema (0.7%). African American or Hispanic background (70% African American, 68% Hispanic vs 73% Caucasian), younger patients (66.1% <65 years vs 78.6% >65 years), and male gender (69.9% vs 72.1%; all P < .001) all had lower rates. Compared to 2005, more patients were current with guidelines (71% vs 64%) and colonoscopic screening (83% vs 71%). CONCLUSIONS: Although ethnicity-, gender-, and age-related disparities were observed, screening rates are improved in an equal access healthcare system.

National trends and outcomes for the surgical therapy of ileocolonic Crohn's disease: a population-based analysis of laparoscopic vs. open approaches.

PURPOSE: The laparoscopic approach to Crohn's disease has demonstrated benefits in several small series. We sought to examine its use and outcomes on a national level. METHODS: All admissions with a diagnosis of Crohn's disease requiring bowel resection were selected from the 2000-2004 Nationwide Inpatient Sample. Regression analyses were used to compare outcome measures and identify independent predictors of undergoing laparoscopy. RESULTS: Of 396,911 patients admitted for Crohn's disease, 49,609 (12%) required surgical treatment. They were predominately Caucasian (64%), female (54%), and with ileocolic disease (72%). Most had private insurance (71%) and had surgery in urban hospitals (91%). Laparoscopic resection was performed in 2,826 cases (6%) and was associated with lower complications (8% vs. 16%), shorter length of stay (6 vs. 9 days), lower charges ($27,575 vs. $38,713), and mortality (0.2% vs. 0.9%, all P < 0.01). Open surgery was used more often for fistulas (8% vs. 1%) and when ostomies were required (12% vs. 7%). Independent predictors of laparoscopic resection were age <35 [odds ratio (OR) = 2.4], female gender (OR = 1.4), admission to a teaching hospital (OR = 1.2), ileocecal location (OR = 1.5), and lower disease stage (OR = 1.1, all P < 0.05). Ethnic category, insurance status, and type of admission (elective vs. non-elective) were not associated with operative method (P > 0.05). CONCLUSIONS: A variety of patient- and system-related factors influence the utilization of laparoscopy in Crohn's disease. Laparoscopic resection is associated with excellent short-term outcomes compared to open surgery.

Mesonephric remnant with tubular function in a 15-year-old female.

Congenital abnormalities of the genital or urinary tract are not uncommon and often occur together. This article discusses a unique case in which a functioning mesonephric remnant was found.

Lipoxin biosynthesis in inflammatory bowel disease.

BACKGROUND AND AIMS: Lipoxins are anti-inflammatory lipid mediators that are produced in gut mucosa, which serve to limit and resolve persistent inflammation. The purpose of this study was to evaluate colonic lipoxin biosynthesis in patients with ulcerative colitis (UC) to establish a possible biochemical basis for persistent inflammation in UC. METHODS: Colonic mucosa from patients with UC or organ donors (controls) was placed into tissue culture for 90 min. The conditioned media was assayed (ELISA) for lipoxin A4 (LXA) and the biologically active isomer 15-epi-LXA4 (aspirin triggered lipoxin, ATL). Mucosal tissue 15-lipoxygenase protein was determined by Western blot. RESULTS: Patient colonic mucosa produced significantly lower (12-fold) amounts of LXA, relative to organ donors. This occurred irregardless of patient steroid treatment. However, patient tissue responded to in vitro aspirin by synthesizing biologically active ATL. For the first time, human colonic mucosa was found to synthesize 15-lipoxygenase-2, an epithelial-derived isoenzyme used for lipoxin synthesis. These levels were significantly lower in UC patients compared to the control tissue. Finally, mice chronically treated with a putative selective 15-lipoxygenase inhibitor (PD 146176) experienced significantly worse intestinal function during experimental colitis, relative to untreated mice. CONCLUSION: Colonic mucosa from UC patients demonstrated defective lipoxin biosynthesis, which may contribute to the inability of these patients to resolve persistent colonic inflammation.

Role of peroxynitrite anion in renal hypothermic preservation injury.

BACKGROUND: Peroxynitrite anions may play a role in normothermic renal ischemia and reperfusion. The purpose of this study was to determine if endogenous peroxynitrite anion is involved in renal preservation injury. METHODS: Experiments were conducted in isolated canine renal tubules and in a canine autotransplant model of hypothermic preservation injury. RESULTS: Isolated renal tubules demonstrated progressive loss of membrane transport function after reperfusion with increasing cold storage times in UW solution as assessed by tetraethylammonium cation transport (TEA). This transport defect was not altered by reperfusion in the presence of WW85, a peroxynitrite decomposition catalyst. Likewise, tubule LDH release was not altered by WW85. Renal tubules did not demonstrate any evidence of peroxynitrite formation after cold storage (0-120 h) or after subsequent reperfusion in vitro as measured by nitrotyrosine adduct formation. Addition of exogenous peroxynitrite (1 mM) directly to freshly isolated renal tubules produced strong nitrotyrosine signals but failed to alter membrane function (TEA uptake). Conversely, SIN-1, a peroxynitrite generator molecule, failed to produce a nitrotyrosine signal in extracted renal tubule proteins but significantly impaired transport function. Finally, function of cold stored canine autografts was not affected by the scavenging of peroxynitrite anions (WW85) before kidney harvest and immediately at reperfusion. Tissue biopsies from cold stored kidney autografts also failed to show evidence of peroxynitrite synthesis either after cold storage (72 h) or after kidney transplantation (60 min reperfusion). CONCLUSIONS: This study concludes that peroxynitrite anions are not formed and are not involved in renal preservation injury.