Circulating SMRP and CA-125 before and after pleurectomy decortication for pleural mesothelioma.

BACKGROUND: Tumor recurrence remains the main barrier to survival after surgery for pleural mesothelioma (PM). Soluble mesothelin-related protein (SMRP) and cancer antigen 125 (CA-125) are established blood-based biomarkers for monitoring PM. We prospectively studied the utility of these biomarkers after pleurectomy decortication (PD). METHODS: Patients who underwent PD and achieved complete macroscopic resection with available preoperative SMRP levels were included. Tumor marker levels were determined within 60 days of three timepoints: (1) preoperation, (2) post-operation, and (3) recurrence. RESULTS: Of 356 evaluable patients, 276 (78%) had recurrence by the end of follow-up interval. Elevated preoperative SMRP levels were associated with epithelioid histology (p < 0.013), advanced TNM (p < 0.001) stage, and clinical stage (p < 0.001). Preoperative CA-125 levels were not significantly associated with clinical covariates. Neither biomarker was associated with survival or disease-free survival. With respect to nonpleural and nonlymphatic recurrences, mean SMRP levels were elevated in patients with pleural (p = 0.021) and lymph node (p = 0.042) recurrences. CA-125 levels were significantly higher in patients with abdominal (p < 0.001) and lymph node (p = 0.004) recurrences. Among patients with all three timepoints available, we observed an average decrease in SMRP levels by 1.93 nmol/L (p < 0.001) postoperatively and again an average increase at recurrence by 0.79 nmol/L (p < 0.001). There were no significant changes in levels of CA-125 across the study timepoints (p = 0.47). CONCLUSIONS: Longitudinal changes in SMRP levels corresponded with a radiographic presence of disease in a subset of patients. SMRP surveillance could aid in detection of local recurrences, whereas CA-125 could be helpful in recognizing abdominal recurrences.

ECPELLA: Beyond a Left Ventricular Venting Strategy When to Unload the Left Ventricle and How to Decide.

Left ventricular (LV) unloading has been shown to improve survival for patients requiring veno-arterial extracorporeal membrane oxygenation (VA ECMO) support for cardiogenic shock. A mortality benefit has been shown for ECMO and concomitant placement of a transcatheter unloading LV pump such as an Impella device (colloquially referred to as ECPELLA or ECMELLA) for patients resuscitated with VA ECMO after a short period of cardiac arrest. Despite the described benefit of LV unloading with VA ECMO for cardiopulmonary resuscitation, it remains unclear as to what criteria should be used and what other diagnostic and therapeutic adjuncts may be useful. We describe here the successful utilization of concomitant VA ECMO and Impella in a 43 year old male with acute heart failure and cardiac arrest. Distinguishing itself from the currently reported methods, our methodology incorporates transesophageal echocardiography (TEE) in the emergency department for rapid decision-making in addition to an automatic chest compression device, the Lund University Cardiac Assist System (LUCAS) device (Stryker, Portage, MI) as a bridge to LV unloading in a hybrid operating suite.

Anastomotic Stricture After Minimally Invasive Esophagectomy.

BACKGROUND: Despite improved outcomes, minimally invasive esophagectomy (MIE) continues to be associated with anastomotic strictures. Most resolve after a single dilation; however, some become refractory. Little is known about strictures after MIE in North America. METHODS: We performed a single-institution retrospective review of MIEs from 2015 to 2019. Primary outcomes were the proportion of patients requiring anastomotic dilation and the dilation rate per year. Univariate analyses of patients undergoing dilation by various risk factors were performed with nonparametric tests, and multivariate analyses of the dilation rate were conducted using generalized linear models. RESULTS: Of 391 included patients, 431 dilations were performed on 135 patients (34.5%, 3.2 dilations per patient who required at least 1 per patient). One complication occurred after dilation. Comorbidities, tumor histology, and tumor stage were not significantly associated with stricture. Three-field MIE was associated with a higher percentage of patients undergoing dilation (48.9% vs 27.1%, P < .001) and a higher rate of dilations (0.944 vs 0.441 dilations per year, P = .007) than 2-field MIE, and this association remained significant after controlling for covariates. When accounting for surgeon variability, this difference was no longer significant. Among patients with 1 or more dilations, those receiving dilation within 100 days of surgery needed more subsequent dilations (2.0 vs 0.6 dilations per year, P < .001). CONCLUSIONS: After controlling for multiple variables, a 3-field MIE approach was associated with a higher rate of repeat dilations in patients undergoing MIE. A shorter interval between esophagectomy and initial dilation is strongly associated with the need for repeated dilations.

Incidence of Clinically Relevant Solitary Pulmonary Nodules Utilizing a Universal Health Care System.

INTRODUCTION: Solitary pulmonary nodules (SPNs) are common, but the clinical relevance of these nodules is unknown. Utilizing current screening guidelines, we sought to better characterize the national incidence of clinically important SPNs within the largest universal health care system in the nation. MATERIALS AND METHODS: TRICARE data were queried to identify SPNs for ages 18-64 years. SPNs that had been diagnosed within a year with no prior oncologic history were included to ensure true incidence. A proprietary algorithm was applied to determine clinically significant nodules. Further analysis characterized incidence by age grouping, gender, region, military branch, and beneficiary status. RESULTS: A total of 229,552 SPNs were identified with a 60% reduction seen after application of the clinical significance algorithm (N = 88,628). The incidence increased in each decade of life (all P < 0.01). Adjusted incident rate ratios were significantly higher for SPNs detected in the Midwest and Western regions. The incident rate ratio was also higher in females (1.05, confidence interval [CI] 1.018, P = 0.001) as well as non-active duty members (dependents = 1.4 and retired = 1.6, respectively, CIs 1.383-1.492 and 1.591-1.638, P < 0.01). The incidence calculated per 1,000 patients overall was 3.1/1,000. Ages 44-54 years had an incidence of 5.5/1,000 patients, which is higher than the previously reported incidence of < 5.0 nationally for the same age group. CONCLUSIONS: This analysis represents the largest evaluation of SPNs to date combined with clinical relevance adjustment. These data suggest a higher incidence of clinically significant SPNs starting at an age of 44 years in nonmilitary or retired women localized to the Midwest and Western regions of the United States.

Adverse Outcomes Associated With Atrial Arrhythmias After Veno-Venous Extracorporeal Membrane Oxygenation.

Veno-venous extracorporeal membrane oxygenation (VV ECMO) is used as a treatment modality in those who fail to respond to conventional care. Hypoxia and medications used in the intensive care unit may increase risk for atrial arrhythmias (AA). This study aims to evaluate the impact of AA on post-VV ECMO outcome. A retrospective review of patients who were placed on VV ECMO between October 2016 and October 2021. One hundred forty-five patients were divided into two groups, AA and no AA. Baseline characteristic and potential risk factors were assessed. Uni- and multivariate analysis using logistic regression models were constructed to evaluate the predictors of mortality between groups. Survival between groups was estimated by the Kaplan-Meier method using the log-rank test. Advanced age with history of coronary artery disease and hypertension were associated with increased risk to develop AA post-VV ECMO placement ( p value < 0.05). Length on ECMO, time intubated, hospital length of stay, and sepsis were significantly increased in patients in the AA group ( p value < 0.05). There was no difference in the overall mortality between the two groups. AAs were associated with worse hospital course and complications but no difference in overall mortality rate. Age and cardiovascular disease seem to be predisposing risk factors for this. Further studies are needed to investigate potential strategies to prevent AAs development in this population.

Pectin based biologic Velcro effectively seals traumatic solid organ and small bowel injuries.

INTRODUCTION: Injuries to the liver and small bowel are common in multiple injuries. While there are currently a variety of accepted damage-control techniques to expeditiously manage such injuries, morbidity and mortality remain high. Pectin polymers have previously been shown to effectively seal visceral organ injuries ex vivo through physiochemical entanglement with the glycocalyx. We sought to compare the standard of care for the management of penetrating liver and small bowel injuries with a pectin-based bioadhesive patch in a live animal model. METHODS: Fifteen adult male swine underwent a laparotomy with standardized laceration to the liver. Animals were randomized to one of three treatment arms: packing with laparotomy pads (n = 5), suture repair (n = 5), or pectin patch repair (n = 5). Following 2 hours of observation, fluid was evacuated from the abdominal cavity and weighed. Next, a full-thickness small bowel injury was created, and animals were randomized to either a sutured repair (n = 7) or pectin patch repair (n = 8). The segment of bowel was then pressurized with saline, and the burst pressure was recorded. RESULTS: All animals survived the protocol to completion. There were no clinically significant differences between groups regarding baseline vitals or laboratory studies. On one-way analysis of variance, there was a statistically significant difference between groups regarding blood loss after liver repair (26 mL suture vs. 33 mL pectin vs. 142 mL packing, p < 0.01). On post hoc analysis, there was no statistically significant difference between suture and pectin ( p = 0.9). After repair, small bowel burst pressures were similar between pectin and suture repair (234 vs. 224 mm Hg, p = 0.7). CONCLUSION: Pectin-based bioadhesive patches performed similarly to the standard of care for the management of liver lacerations and full-thickness bowel injuries. Further testing is warranted to assess the biodurability of a pectin patch repair, as it may offer a simple option to effectively temporize traumatic intra-abdominal injuries.

Bioadhesive patch as a parenchymal sparing treatment of acute traumatic pulmonary air leaks.

INTRODUCTION: Traumatic pulmonary injuries are common in chest trauma. Persistent air leaks occur in up to 46% of patients depending on injury severity. Prolonged leaks are associated with increased morbidity and cost. Prior work from our first-generation pectin patches successfully sealed pulmonary leaks in a cadaveric swine model. We now test the next-generation pectin patch against wedge resection in the management of air leaks in anesthetized swine. METHODS: A continuous air leak of 10% to 20% percent was created to the anterior surface of the lung in intubated and sedated swine. Animals were treated with a two-ply pectin patch or stapled wedge resection (SW). Tidal volumes (TVs) were recorded preinjury and postinjury. Following repair, TVs were recorded, a chest tube was placed, and animals were observed for presence air leak at closure and for an additional 90 minutes while on positive pressure ventilation. Mann-Whitney U test and Fisher's exact test used to compare continuous and categorical data between groups. RESULTS: Thirty-one animals underwent either SW (15) or pectin patch repair (PPR, 16). Baseline characteristics were similar between animals excepting baseline TV (SW, 10.3 mL/kg vs. PPR, 10.9 mL/kg; p = 0.03). There was no difference between groups for severity of injury based on percent of TV loss (SW, 15% vs. PPR, 14%; p = 0.5). There was no difference in TV between groups following repair (SW, 10.2 mL/kg vs. PPR, 10.2 mL/kg; p = 1) or at the end of observation (SW, 9.8 mL/kg vs. PPR, 10.2 mL/kg; p = 0.4). One-chamber intermittent air leaks were observed in three of the PPR animals, versus one in the SW group ( p = 0.6). CONCLUSION: Pectin patches effectively sealed the lung following injury and were noninferior when compared with wedge resection for the management of acute traumatic air leaks. Pectin patches may offer a parenchymal sparing option for managing such injuries, although studies evaluating biodurability are needed.

A Case Report of Combat Blast Injury Requiring Combat Casualty Care, Far-Forward ECMO, Air Transport, and All Levels of Military Critical Care.

We describe a 34-year-old soldier who sustained a blast injury in Syria resulting in tracheal 5 cm tracheal loss, cervical spine and cord injury with tetraplegia, multiple bilateral rib fractures, esophageal injury, traumatic brain injury, globe evisceration, and multiple extremity soft tissue and musculoskeletal injuries including a left tibia fracture with compartment syndrome. An emergent intubation of the transected trachea was performed in the field, and the patient was resuscitated with whole blood prehospital. During transport to the Role 2, the patient required cardiopulmonary resuscitation for cardiac arrest. On arrival, he underwent a resuscitative thoracotomy and received a massive transfusion exclusively with whole blood. A specialized critical care team transported the patient to the Role 3 hospital in Baghdad, and the DoD extracorporeal membrane oxygenation (ECMO) team was activated secondary to his unstable airway and severe hypoxia secondary to pulmonary blast injury. The casualty was cannulated in Baghdad approximately 40 hours after injury with bifemoral cannulae in a venovenous configuration. He was transported from Iraq to the U.S. Army Institute of Surgical Research Burn Center in San Antonio without issue. Extracorporeal membrane oxygenation support was successfully weaned, and he was decannulated on ECMO day 4. The early and en route use of venovenous ECMO allowed for maintenance of respiratory support during transport and bridge to operative management and demonstrates the feasibility of prolonged ECMO transport in critically ill combat casualties.

Extended Resections for Lung Cancer.

This article briefly reviews the literature supporting the practice of extended pulmonary resection followed by a comprehensive description of the indications, workup, and technique commonly used for patients requiring extended pulmonary resections for advance lung cancers. The article also provides up-to-date advances in the field that have aided in the safe and effective practice of extended pulmonary resections.

Endoluminal Vacuum Therapy for Definitive Management of an Esophagobronchial Fistula.

PURPOSE: Endoluminal vacuum (EVAC) therapy has gained popularity as a minimally invasive option for contained esophageal leaks. EVAC therapy may be useful for esophagogastric anastomotic leak fistulizing to the airway. DESCRIPTION: This report describes EVAC therapy of an esophagobronchial fistula with video depicting the procedure, including technical tips. Video and photographic evidence of progression and ultimate resolution is included. EVALUATION: Sponge exchanges were completed every 3 to 4 days. EVAC therapy was administered through a transnasal approach. In the presented case, a total of 11 exchanges over 6 weeks were required. EVAC sponge placement was transitioned from intracavitary to endoluminal for the final 4 treatments. All but 4 exchanges were able to be completed at the bedside in a monitored setting with sedation. CONCLUSIONS: An esophageal leak that has fistulized to a main airway is a rare and challenging clinical problem. Definitive EVAC therapy for esophageal anastomotic leak with esophagobronchial fistula is a feasible option in selected cases.

Combatting ischemia reperfusion injury from resuscitative endovascular balloon occlusion of the aorta using adenosine, lidocaine and magnesium: A pilot study.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA), a minimally invasive alternative to resuscitative thoracotomy, has been associated with significant ischemia reperfusion injury (IRI). Resuscitation strategies using adenosine, lidocaine, and magnesium (ALM) have been shown to mitigate similar inflammatory responses in hemorrhagic and septic shock models. This study examined the effects of ALM on REBOA-associated IRI using a porcine model. METHODS: Animals underwent a 20% controlled hemorrhage followed by 30 minutes of supraceliac balloon occlusion. They were assigned to one of four groups: control (n = 5), 4-hour ALM infusion starting at occlusion, 2-hour (n = 5) and 4-hour (n = 5) interventional ALM infusions starting at reperfusion. Adenosine, lidocaine, and magnesium cohorts received a posthemorrhage ALM bolus followed by their respective ALM infusion. Primary outcomes for the study assessed physiologic and hemodynamic parameters. RESULTS: Adenosine, lidocaine, and magnesium infusion after reperfusion cohorts demonstrated a significant improvement in lactate, base deficit, and pH in the first hour following systemic reperfusion. At study endpoint, continuous ALM infusion initiated after reperfusion over 4 hours resulted in an overall improved lactate clearance when compared with the 2-hour and control cohorts. No differences in hemodynamic parameters were noted between ALM cohorts and controls. CONCLUSION: Adenosine, lidocaine, and magnesium may prove beneficial in mitigating the inflammatory response seen from REBOA-associated IRI as evidenced by physiologic improvements early during resuscitation. Despite this, further refinement should be sought to optimize treatment strategies.

Efficacy and safety of bariatric revisions in patients older than 65 years old.

BACKGROUND: Bariatric surgery in advanced age patients (>65-years-old) has been proven safe and effective. Revisional bariatric surgery is infrequently required for cases of refractory obesity. However, there is a paucity of data regarding revisional surgery for the elderly. We hypothesize that revisional bariatric surgery is viable and safe in elderly patients. METHODS: Retrospective chart review of all bariatric revisions performed at two high-volume bariatric centers of excellence between 2011 and 2018. Perioperative and long-term outcomes were compared between patients >65 and those <65-years-old. RESULTS: 145 bariatric revisions were performed for weight loss. 10% (N = 15) were >65 years old. There were no differences in mortality between the two groups There was a longer median length of stay in the younger cohort (2 vs 1 day, p = 0.001). Percent excess weight loss was similar at 12-months, as was resolution of comorbidities. CONCLUSIONS: Bariatric revisions in elderly patients appears to be safe and effective. Revisional surgery in this population was not shown to have increased morbidity or mortality with similar excess body weight loss when compared to a younger cohort.

Mobile Smartphone Thermal Imaging Characterization and Identification of Microvascular Flow Insufficiencies in Deep Inferior Epigastric Artery Perforator Free Flaps.

BACKGROUND: Mobile smartphone thermal imaging (MTI) devices correlate with blood flow, which makes them appealing adjuncts during reconstructive surgery. MTI was assessed in the setting of deep inferior epigastric artery perforator (DIEAP) free flaps. We hypothesized that MTI can be a surrogate for blood flow to identify microvascular flow insufficiencies. METHODS: Nineteen patients underwent 30 DIEAP flaps for breast reconstruction. Images were obtained preoperatively, intraoperatively, and at instances of concern for flap viability. Three groups were evaluated: normal DIEAP flaps (NDFs), flaps with arterial insufficiency (AI), and flaps with venous congestion (VC). RESULTS: All flaps were successful. There were significant temperature increases from max ischemia (24.5 ± 2.1°C) to 1 min after anastomosis (27.2 ± 1.6°C, P < 0.001). NDFs continued to warm until the final MTI was taken when leaving the operating room. There were no differences between MTI flap temperatures before transfer to the chest and after completion of microanastomosis. With questionable flap viability, VC and AI temperatures were found to be significantly colder than the NDF group (28.3 ± 1.9°C versus 32.2 ± 1.8°C, P = 0.003) in the VC group and (27.2 ± 0.7°C versus 32.2 ± 1.8°C, P = 0.001) in the AI group. After correction of the identified flow insufficiency, VC and AI rewarmed and temperatures were no different compared with NDF. CONCLUSIONS: MTI recognizes microanastomotic failure and is a practical adjunct in the evaluation of free flap perfusion.

Improved outcomes utilizing a novel pectin-based pleural sealant following acute lung injury.

BACKGROUND: Persistent air leaks after thoracic trauma are associated with significant morbidity. To evaluate a novel pectin sealant in a swine model of traumatic air leaks, we compared a pectin biopolymer with standard surgical and fibrin-based interventions. METHODS: A standardized lung injury was created in male Yorkshire swine. Interventions were randomized to stapled wedge resection (n = 5), topical fibrin glue (n = 5), fibrin patch (n = 5), and a pectin sealant (n = 6). Baseline, preintervention and postintervention tidal volumes (TV) were recorded. Early success was defined as the return to near-normal TV (>95% of baseline). Late success was defined as no detectable air leak in the chest tube after chest closure. RESULTS: There were no differences in injury severity between groups (mean TV loss, 62 ± 17 mL, p = 0.2). Early success was appreciated in 100% (n = 6) of the pectin interventions which was significantly better than the fibrin sealant (20%, n = 1), fibrin patch (20%, n = 1), and stapled groups (80%, n = 4, p = 0.01). The percent of return to baseline TV after sealant intervention was significantly increased in the pectin (98%) and staple arms (97%) compared with the fibrin sealant (91%) and fibrin patch arms (90%) (p = 0.02; p = 0.03). Late success was also improved with the pectin sealant: no air leak was detected in 83% of the pectin group compared with 40% in the stapled group (p = 0.008)-90% of the fibrin-based interventions resulted in continuous air leaks (p = 0.001). CONCLUSION: Pectin-based bioadhesives effectively seal traumatic air leaks upon application in a porcine model. Further testing is warranted as they may provide a superior parenchymal-sparing treatment option for traumatic air leaks.

Validation of a novel partial resuscitative endovascular balloon occlusion of the aorta device in a swine hemorrhagic shock model: Fine tuning flow to optimize bleeding control and reperfusion injury.

OBJECTIVES: Partial restoration of aortic flow during resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated by some to mitigate distal ischemia. Our laboratory has validated the mechanics and optimal partial REBOA (pREBOA) flow rates using a prototype device. We hypothesize that pREBOA will increase survival when compared with full REBOA (fREBOA) in prolonged nonoperative management of hemorrhagic shock. METHODS: Twenty swine underwent placement of aortic flow probes, zone 1 REBOA placement, and 20% blood volume hemorrhage. They were randomized to either solid organ or abdominal vascular injury. The pREBOA arm (10 swine) underwent full inflation for 10 minutes and then deflation to a flow rate of 0.5 L/min for 2 hours. The fREBOA arm (10 swine) underwent full inflation for 60 minutes, followed by deflation/resuscitation. The primary outcome is survival, and secondary outcomes are serologic/pathologic signs of ischemia-reperfusion injury and quantity of hemorrhage. RESULTS: Two of 10 swine survived in the fREBOA group (2/5 solid organ injury; 0/5 abdominal vascular injury), whereas 7 of 10 swine survived in the pREBOA group (3/5 solid organ injury, 4/5 abdominal vascular injury). Survival was increased (p = 0.03) and hemorrhage was higher in the pREBOA group (solid organ injury, 1.36 ± 0.25 kg vs. 0.70 ± 0.33 kg, p = 0.007; 0.86 ± 0.22 kg vs. 0.71 ± 0.28 kg, not significant). Serum evidence of ischemia was greater with fREBOA, but this was not significant (e.g., lactate, 16.91 ± 3.87 mg/dL vs. 12.96 ± 2.48 mg/dL at 120 minutes, not significant). Swine treated with pREBOA that survived demonstrated trends toward lower alanine aminotransferase, lower potassium, and higher calcium. The potassium was significantly lower in survivors at 60 minutes and 90 minutes time points (5.97 ± 0.60 vs. 7.53 ± 0.90, p = 0.011; 6.67 ± 0.66 vs. 8.15 ± 0.78, p = 0.029). Calcium was significantly higher at 30 minutes, 60 minutes, and 90 minutes (8.56 ± 0.66 vs. 7.50 ± 0.40, p = 0.034; 8.63 ± 0.62 vs. 7.15 ± 0.49, p = 0.019; 8.96 ± 0.64 vs. 7.00, p = 0.028). CONCLUSION: Prolonged pREBOA at a moderate distal flow rate provided adequate hemorrhage control, improved survival, and had evidence of decreased ischemic injury versus fREBOA. Prophylactic aggressive calcium supplementation may have utility before and during the reperfusion phase.

Early outcomes following trauma related to sex: A matched analysis of military service members in the department of defense trauma registry.

BACKGROUND: Several studies have identified sex as a factor influencing early outcomes after trauma. With the increased representation of women in combat roles, there is a need for improved understanding of the pathophysiology of traumatic injury in women. The purpose of this study was to define sex-based differences in early combat trauma outcomes amongst military service members. METHODS: A retrospective review of the Department of Defense Trauma Registry between 2008 and 2016 was performed. A 2:1 case control match was performed to match for Injury Severity Score, mechanism of injury, and age. The primary outcome of the study was mortality. RESULTS: A total of 4,625 patients were included in the study, 2.2% of whom were women. Women were less significantly injured than men (Injury Severity Score, 7.7 vs. 11, p = 0.003) and more likely to sustain blunt trauma (81% vs. 62.5%, p = 0.01). After case-control matching, 202 men and 101 women were evaluated. There was no statistical difference in the primary outcome of mortality. There was no statistical difference in Glasgow Coma Scale score, crystalloid or colloid administration, Packed Red Blood Cells (PRBC), platelet, cryoprecipitate, or plasma usage between men and women. CONCLUSION: Contrary to the civilian trauma literature, our study demonstrated no significant difference in early mortality between male and female combat casualties in a matched cohort. This finding may represent a difference in injury patterns, resuscitation practices, or lifesaving interventions in a deployed setting as compared with civilian setting. As the proportion of women involved in combat operations continues to increase, prospective studies should be performed to better define injury patterns, as well as early and late outcomes related to military trauma in the female population. LEVEL OF EVIDENCE: Retrospective, Level IV.

Extraction bags provide no benefit when compared to unprotected lateral stomach extraction during laparoscopic sleeve gastrectomy.

BACKGROUND: Currently, no evidence compares outcomes for techniques utilizing surgical specimen extractions bags versus unprotected extraction. METHODS: Evaluation of sleeve gastrectomies performed at two high-volume centers. Cases where an extraction bag was used (+EB) were compared to bag-less extraction (-EB). Outcomes included operative contamination, surgical site infections and extraction-site hernias. RESULTS: 674 patients were evaluated (417 in the +EB group and 257 in the -EB group). Preoperative characteristics were similar between groups. There was a trend toward shorter operative times with the -EB group (-EB = 100 min vs + EB = 106 min, p = 0.07). Gross spillage was documented as a contaminated case in 0.4% of -EB cases compared to 1.2% in +EB cases (p = 0.51). Two superficial infections were appreciated (1.2% = +EB vs 0.7% = -EB, p = 0.7) with one post-operative abscess in the -EB group (p = 0.61). One post-operative hernia was seen in each group (p = 0.62). DISCUSSION: Bag-less extraction is a safe, resource conscious method that may potentially decreased operative time.

A simple technique for neoumbilical reconstruction for congenital hernia associated proboscis deformity.

INTRODUCTION: Umbilical reconstruction in pediatric patients who have developed a large proboscoid redundancy can be challenging after standard umbilical repair. We present a simple and unique surgical technique that results in a cosmetically appealing reconstruction. OPERATIVE TECHNIQUE: The operation is initiated with circumferential redundant skin excision and isolation of the hernia sac. Primary fascial repair is performed. Reconstruction utilizes the cut dermal/epidermal edge by approximating it to the exposed fascia just below the skin edge outside of the fascial repair in a purse string fashion for the creation of a neoumbilicus. CONCLUSION: This simple technique is unique from any currently published methods and results in a cosmetically pleasing reconstruction without evidence of any incision. LEVEL OF EVIDENCE: Level V: Expert Opinion.