Transcarotid artery revascularization in blunt carotid injury.

Introduction: Transcarotid artery revascularization (TCAR) with flow reversal has substantially changed the management of carotid artery stenosis, enabling an endovascular approach with a periprocedural stroke rate as low as or lower than that of open carotid surgery. The use of TCAR for blunt carotid artery injury has not yet been described. Methods: A review of the use of TCAR for blunt carotid artery injury was performed at a single center from October 2020 to August 2021. The patient demographics, mechanism of injury, and outcomes were collected and compared. Results: Ten carotid stents were placed via TCAR in eight patients for hemodynamically significant blunt carotid artery injuries. No periprocedural neurologic events occurred, and all stents remained patent during short-term follow-up. Conclusions: TCAR is feasible and safe in the management of significant blunt carotid artery injuries. More data are needed regarding the long-term outcomes and ideal surveillance intervals.

Influence of Covid-19 Restrictions on Urban Violence.

We investigated whether the COVID-19 pandemic affected rates of interpersonal violence (IV). A retrospective study was performed using city-wide crime data and the trauma registry at one high-volume trauma center pre-pandemic [PP] (March-October 2019) and during the pandemic [PA] (March-October 2020). The proportion of trauma admissions attributable to IV remained unchanged from PP to PA, but IV increased as a proportion of overall crime (34% to 41%, p<0.001). Assaults decreased, but there was a proportionate increase in penetrating trauma which was mostly attributable to firearms. Despite a reduction in admissions due to IV in the first 4 months of the pandemic, the rates of violence subsequently exceeded that of the same months in 2019. The cause of the observed increase of IV is multi-factorial. Future studies aimed at identifying the root causes are essential to mitigate violence during this ongoing health crisis.

Initiation of an Intraoperative Radiotherapy Program at a Safety net Hospital: What Is the Impact of an Intraoperative Radiotherapy Program in Underserved Patients With Early Breast Cancer?

BACKGROUND: Intraoperative radiotherapy (IORT) can allow for single-dose radiation treatment following breast conservation therapy in low-risk patients with early breast cancer, in lieu of a traditional 6-week course of whole breast radiotherapy (WBRT). The objective of this study was to analyze the uptake and utilization of an IORT program in a safety-net hospital. MATERIALS AND METHODS: A retrospective review was conducted for all patients who underwent IORT from September 2014 to June 2018. Patient demographics, tumor characteristics, and IORT outcomes were analyzed. The proportion of patients undergoing IORT were determined to assess utilization and uptake. RESULTS: There were 27 female patients that received IORT, 23 (85.2%) of which required no further radiotherapy. Three (7.4%) patients had positive axillary lymph nodes and/or positive margins requiring subsequent WBRT. One patient (3.7%) developed an in-breast recurrence distant from the lumpectomy site 23 months after IORT. Ten patients (37.0%) developed a postoperative complication, including 5 seromas and 6 wound complications (superficial infections and/or wound necrosis). Overall, in the 46-month study period, IORT accounted for only 6.4% of 423 operations. Still, 27 of 29 (93.1%) patients who met eligibility criteria for IORT underwent the procedure. DISCUSSION: Although IORT comprised only 6.4% of all cases due to higher rates of mastectomy rates and advanced disease in our population, there was a high uptake of IORT among patients who met eligibility criteria for the procedure. Major complication rates of IORT were low, and most patients successfully completed radiotherapy in 1 intraoperative dose.

Traumatic bile duct neuroma presenting with acute cholangitis: A case report and review of literature.

Traumatic neuroma of the biliary tree has been previously reported as isolated case reports. In literature, these typically present following prior liver transplant or cholecystectomy, wherein the bile ducts have been disrupted in some form. Here we report the case of a 41-year old male who initially presented with acute cholangitis ten years after an open cholecystectomy complicated by a bile leak. Endoscopic retrograde cholangiography revealed a stricture within the mid distal common hepatic duct. The patient temporarily resolved his initial episode with stent placement, and he was eventually taken to the operating room for bile duct resection and hepaticojejunostomy given a persistent stricture and concern for underlying malignancy. Final pathology demonstrated a traumatic bile duct neuroma. This unusual entity should be considered in patients with benign appearing strictures presenting years after surgery, and awareness may aid in preoperative counseling as well.

Infection after penetrating brain injury-An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15-19, 2019, in Austin, Texas.

BACKGROUND: Fatality rates following penetrating traumatic brain injury (pTBI) are extremely high and survivors are often left with significant disability. Infection following pTBI is associated with worse morbidity. The modern rates of central nervous system infections (INF) in civilian survivors are unknown. This study sought to determine the rate of and risk factors for INF following pTBI and to determine the impact of antibiotic prophylaxis. METHODS: Seventeen institutions submitted adult patients with pTBI and survival of more than 72 hours from 2006 to 2016. Patients were stratified by the presence or absence of infection and the use or omission of prophylactic antibiotics. Study was powered at 85% to detect a difference in infection rate of 5%. Primary endpoint was the impact of prophylactic antibiotics on INF. Mantel-Haenszel χ and Wilcoxon's rank-sum tests were used to compare categorical and nonparametric variables. Significance greater than p = 0.2 was included in a logistic regression adjusted for center. RESULTS: Seven hundred sixty-three patients with pTBI were identified over 11 years. 7% (n = 51) of patients developed an INF. Sixty-six percent of INF patients received prophylactic antibiotics. Sixty-two percent of all patients received one dose or greater of prophylactic antibiotics and 50% of patients received extended antibiotics. Degree of dural penetration did not appear to impact the incidence of INF (p = 0.8) nor did trajectory through the oropharynx (p = 0.18). Controlling for other variables, there was no statistically significant difference in INF with the use of prophylactic antibiotics (p = 0.5). Infection was higher in patients with intracerebral pressure monitors (4% vs. 12%; p = <0.001) and in patients with surgical intervention (10% vs. 3%; p < 0.001). CONCLUSION: There is no reduction in INF with prophylactic antibiotics in pTBI. Surgical intervention and invasive intracerebral pressure monitoring appear to be risk factors for INF regardless of prophylactic use. LEVEL OF EVIDENCE: Therapeutic, level IV.

Current Burden of Gunshot Wound Injuries at Two Los Angeles County Level I Trauma Centers.

BACKGROUND: Gunshot wound (GSW) injuries present a unique surgical challenge. This study explored the financial and clinical burdens of GSW patients across 2 Los Angeles County Level I trauma centers over the last 12 years, and compared them with other forms of interpersonal injury (OIPI). STUDY DESIGN: This was a retrospective study of patients presenting as those with GSW and OIPI (defined as combined stab wound or blunt assault), between January 1, 2006 and March 30, 2018, at LAC+USC Medical Center (LAC+USC) and Harbor UCLA Medical Center (HUCLA). Demographic and clinical variables were assessed for GSW patients and compared with victims of OIPI. RESULTS: There were 17,871 patients who met inclusion criteria. There was a significant difference in mortality for patients with GSW vs OIPI (11% vs 2%, p < 0.001). The odds ratio for GSW patients requiring operation was twice as high as those suffering OIPI (odds ratio [OR] 2.0, 95% CI 1.8 to 2.2). The odds ratio for GSW patients requiring ICU admission was 20% higher than that for OIPI patients (OR 1.23, 95% CI 1.11 to 1.36). Gunshot wound patients experienced a longer median length of stay vs OIPI patients (3 days vs 2 days, p < 0.001). The median hospital charge per admission for GSW was twice that of OIPI (GSW $12,612 vs OIPI $6,195; p < 0.001). CONCLUSIONS: When compared with OIPI, GSW patients arrived more severely injured and required more operations, more ICU admissions, and longer hospital stays. Patients with GSW incurred significantly higher hospital charges and had a significantly higher mortality rate. Gunshot wound injury is a unique public health concern requiring comprehensive, nation-wide, contemporary study.

Intraoperative Injection of 99m-Tc Sulfur Colloid for Sentinel Lymph Node Biopsy: Can the Preoperative Injection Procedure be Eliminated?

BACKGROUND: Sentinel lymph node biopsy (SLNB) historically involves a separate appointment in the Radiology Department to undergo injection of the radiocolloid tracer (RT) the day of, or prior to, surgery, which can lead to disruptions in scheduling. Furthermore, the patient must endure an additional procedure. In a pilot study, intraoperative injection of the RT was previously shown to be equally as effective as preoperative injection. This study evaluates the efficacy of this method in a large cohort and examines factors associated with failure of the RT to reach the axilla. METHODS: A retrospective review of patients who underwent SLNB between June 2010 and June 2017 was performed. All patients were injected immediately following intubation with sulfur colloid and blue dye, unless contraindicated. Operative records were reviewed to determine whether sentinel nodes were identified and if gamma counts were detected. Patient and tumor characteristics were examined to identify factors related to failed RT uptake in the axilla. RESULTS: In 7 years, 453 SLNBs were performed, with sentinel nodes being detected in 447 (98.7%) of these SLNBs. In the six cases where no nodes were detected, all had a prior ipsilateral axillary procedure. Sentinel nodes were undetectable with the gamma probe in 16 (3.5%) cases; a prior axillary procedure was the only statistically significant independent variable associated with this failure. CONCLUSION: Intraoperative injection of the RT is highly effective in the detection of sentinel nodes in clinically node-negative breast cancer patients. Eliminating the need for a preoperative injection of RT can avoid scheduling conflicts and decrease patient morbidity.

Global comparison of pediatric surgery workforce and training.

INTRODUCTION: The number of pediatric surgeons and their distribution vary greatly throughout the world. The purpose of this study is to examine potential influential factors including the length of education and training, pediatric population, birth rate, and gross domestic product (GDP) per capita. METHODS: An internet search was conducted to determine the duration of education from grade school to pediatric surgery fellowship, number of pediatric surgeons, birth rate, GDP, and population under 15 years of age in 15 countries. The number of pediatric surgeons per million children was correlated with these factors. RESULTS: The number of pediatric surgeons per million children varied from 0.51 to 29.3. The total length of education from grade school to completion of pediatric surgery training ranged from 23 to 29 years. There was no correlation between pediatric surgeons per million children with the duration of training. The number of pediatric surgeon per million children was inversely correlated with the birth rate. There was a positive correlation between the GDP per capita and pediatric surgeons per million children. CONCLUSION: There is a tremendous variability in pediatric surgeons around the world. There appears to be a significant shortage of pediatric surgeons in countries with a high birth rate and low GDP per capita.