Multidisciplinary approach to the management of renal angiomyolipoma with inferior vena cava thrombus and pulmonary embolism: a case report.

Renal angiomyolipoma (AML) is a benign tumor with rare venous extension. We present a case of a patient with renal AML with inferior vena cava (IVC) tumor thrombus and acute pulmonary embolism (PE). A 34-year-old female presented with chest pain. Imaging revealed a 5 cm right renal AML, with tumor thrombus into the renal vein and IVC, and acute left lower lobe PE. Right radical nephrectomy and caval thrombectomy were performed using intraoperative ultrasound. Rarely, these benign tumors generate thrombus with caval extension. The location of IVC thrombus guides surgical planning, which may involve suprahepatic IVC control or cardiopulmonary bypass. Early involvement of a multidisciplinary team with extensive preoperative planning can help achieve successful outcomes.

Attempted repair of chest wall injury following penetrating injury with surgical stabilization rib and autologous bone graft: A case report.

Rib fractures are one of the most common injuries following blunt trauma. When associated with penetrating trauma, the projectile velocity and immense energy transfer cause significant rib fracture displacement and fragmentation. As a result, these patients are potentially exposed to an even higher risk of complications compared to those seen in more simple rib fractures. Unfortunately, there is limited research regarding technical considerations for surgical stabilization of rib fractures (SSRF) in severely displaced rib fractures with bone loss following penetrating injury. We present the case of a 21-year-old male gunshot wound victim with severely displaced and comminuted rib fractures in which we utilized an autologous bone graft bridge during SSRF to enhance fracture unionization, chest wall stability, and cosmesis. Unfortunately, the bone graft failed to incorporate into surrounding tissue.

Hardware failure for anterior chest wall and costal cartilage injuries: A single-center experience.

BACKGROUND: Often missed in blunt chest wall injury, costal cartilage injuries can cause chest wall instability, refractory pain, and deformity. Notably, there is only a small amount of evidence regarding hardware performance when applied to costal cartilage. In a prior multicenter study, hardware failure rate was found to be approximately 3% following surgical stabilization of rib fractures (SSRFs) for all fracture locations. The aim of the current study was to evaluate hardware performance for costal cartilage injuries. METHODS: All patients undergoing SSRF performed at our institution from 2016 to 2022 were queried, including both acute and chronic injuries. Both radiographic and clinical follow-up were retrospectively reviewed to evaluate for hardware failure defined as plate fracture, malposition, or screw migration following cartilage fixation. RESULTS: After screening 359 patients, 43 were included for analysis. Mean age was 64 years, and 67% of patients were male. Median number of fractures per patient was 7 with 60% of patients sustaining a flail chest injury pattern. Median total plates per operation was 6 and median costal cartilage plates was 3. In total, 144 plates were applied to the costal cartilage for the group. Mean follow-up was as follows: clinical 88 days, two-view plain radiography 164 days, and chest computed tomography 184 days. Hardware failure was observed in 3 of 144 plates (2.1%), in three separate patients. Two cases were asymptomatic and did not require intervention. One patient required revisional operation in the acute setting. CONCLUSION: In our institution, hardware failure for costal cartilage fractures was observed to be 2.1%. This aligns with prior reports of hardware failure during SSRF for all injury locations. Surgical stabilization of anterior and cartilaginous chest wall injury with appropriate plate contouring and fixation technique appears to provide adequate stabilization with a relatively low rate of hardware malfunction. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

A paradoxical internal hernia at Brolin's anti-obstruction stitch following Roux-en-Y gastric bypass: a case report.

Internal hernias are a rare but morbid complication following Roux-en-Y gastric bypass surgery. The incorporation of Brolin's anti-obstruction stitch has historically demonstrated a significant reduction in the incidence of internal hernias following Roux-en-Y gastric bypass. We present an ironic and unique case of a patient with small bowel herniation into a defect between Brolin's stitch and the stapled closed common enterotomy of the jejunojejunostomy and technical considerations to decrease internal hernias at this site in the future.

Operative technique for a successful laparoscopic en-bloc resection of gastrogastric fistula following roux-en-Y gastric bypass.

Gastrogastric fistulas are rare complications following Roux-en-Y gastric bypass surgery and are characterized by a fistulous connection between the gastric pouch and the remnant stomach. The presentation is often variable and a high-index of suspicion must be maintained for accurate and timely diagnosis. In this case report, we provide a detailed review of the technical steps taken to successfully resect a gastrogastric fistula en-bloc laparoscopically with an unremarkable post-operative course.

A case report of acute appendicitis complicated by pylephlebitis: medical and surgical management.

Pylephlebitis is a suppurative thrombus of the portal vein and/or its branches secondary to an intra-abdominal infection. Acute appendicitis is the most common cause of emergency operation in general surgery and is typically treated with antibiotics and timely appendectomy with minimal adverse outcomes (Ferris M, Quan S, Kaplan BS, et al. The global incidence of appendicitis: a systematic review of population-based studies. Ann Surg 2017;266:237-41 and Poon S, Lee J, NG KM, Chiu GWY, et al. The current management of acute uncomplicated appendicitis: should there be a change in paradigm? A systematic review of the literatures and analysis of treatment performance. WJES 2017;12:46). Unfortunately, the identification of pyelephlebitis is difficult to make due to its nonspecific clinical presentation and can result in significant morbidity or mortality if not appropriately treated. Certain laboratory derangements and positive intra-abdominal imaging combined with a high index of suspicion can make the diagnosis. Treatment involves broad-spectrum antibiotics, anticoagulation, and source control of the primary nidus of infection. Our case presentation follows the successful clinical course of a young male diagnosed with acute appendicitis complicated by pylephlebitis. He was treated with antibiotics and anticoagulation followed by interval laparoscopic appendectomy with consequential resolution of thrombus on subsequent cross-sectional imaging.

In- and out-of-hospital outcomes following surgical stabilization of rib fractures in 80 years and older: A single-institution experience.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) has demonstrated benefit in patients with flail chest and multiple displaced fractures. There is mounting evidence for SSRF following chest wall injury (CWI) for the geriatric trauma population. A recent multi-center retrospective study highlighted a mortality benefit even for those patients aged 80 years and older. The objective of this investigation was to review our institutional experience with both in- and out-of-hospital outcomes within this patient population following SSRF. METHODS: A retrospective review of patients 80 years and older was performed at a high-volume level 2 trauma center from 2017 to 2021. SSRF volume is routinely >60 cases per year. Perioperative, inpatient, and outpatient data were collected as available. Primary outcomes were inpatient and 90-day mortality. Secondary outcomes included discharge on narcotics and freedom from narcotics at 30 days. RESULTS: 50 patients were included for review. Mean age was 86 years and mechanism of injury was most often fall. 28 of 50 (56%) patients had flail chest (radiographic). Mean number of ribs fixated was 4.7 and time to surgery 2.5 days. Inpatient mortality was 3/50 (6%), 90-day mortality was 9/50 (18%) of which three were attributable primarily to CWI (6/50, 12%). Of patients with follow-up of 1 year and beyond, 27/28 were alive (96%). With respect to narcotic consumption, 45% (21/47) were discharged on narcotics with 90% (28/31; N limited by missing data) being narcotic-free at 30 days. CONCLUSION: In this high-risk patient population, inpatient mortality was comparably low to prior reports, though 90-day mortality was doubled when incorporating CWI-related deaths. Narcotic use was seen in the minority of patients upon discharge, and most progressed to being narcotic-free at 30 days post-hospitalization. Inpatient outcomes alone may not adequately define both the benefit and risk of SSRF performed in patients 80 years and older.

Multidisciplinary Simulation of Trauma in Pregnancy with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Utilization.

Background Studies have demonstrated the use of resuscitative endovascular balloon occlusion catheters of the aorta (REBOA) in the setting of postpartum hemorrhage and traumatic hemorrhagic shock. However, REBOA is infrequently utilized leading to a lack of clinician comfort. This study's aim was to demonstrate the utility of REBOA in a hemorrhaging pregnant trauma patient and improve clinician comfort with the placement of REBOA while emphasizing collaboration between medical specialties. Methods A multidisciplinary in-situ simulation was developed for the management of a pregnant patient with an abdominal gunshot wound evaluated by obstetrics and surgery teams. A trauma survey, emergency c-section, massive transfusion protocol (MTP), and evaluation for and placement of REBOA were indicated during the simulation. A standardized Return on Learning questionnaire was utilized to determine participants' reactions and confidence gained during the simulation. Results A total of 32 of 41 participants completed the survey (78%). A statistically significant increase in confidence was reported in the ability to prioritize the care of a pregnant patient with hemorrhagic shock (p = 0.016), apply MTP to the appropriate clinical setting (p = 0.03), and analyze critical decisions made for abdominal trauma in pregnant patients (p = 0.006). Specifically for physicians, a significant increase in confidence in the ability to identify indications/contraindications for REBOA placement in hemorrhaging patients was observed (p = 0.021). Conclusions A multidisciplinary simulation for the management of a pregnant patient in hemorrhagic shock secondary to penetrating abdominal trauma improved learner confidence in MTP, care of pregnant patients in hemorrhagic shock, and abdominal trauma in pregnancy. Physician learners gained confidence in indications for REBOA placement in abdominal trauma. This simulation was highly relevant to all participants.

Endoscopic and surgical management of Bouveret's syndrome complicated by gallstone ileus.

Bouveret's syndrome is a rare complication that occurs most commonly in elderly patients with multiple comorbidities. It is secondary to an impacted gallstone causing gastric outlet obstruction from a cholecystoduodenal fistula, and there is no defined standardized management in current literature. A 92-year-old woman presents to our tertiary community hospital with abdominal discomfort concerning for bowel obstruction. Computed tomography revealed pneumobilia with a cholecystoduodenal fistula and a large gallstone in the proximal duodenum causing gastric outlet obstruction. The impacted gallstone failed endoscopic extraction with electrohydraulic lithotripsy, and patient subsequently developed distal gallstone ileus requiring exploratory laparotomy and enterolithotomy. This case report examines the need for early coordinated endoscopic and surgical management of a patient with Bouveret's syndrome complicated by gallstone ileus as it is associated with high morbidity and mortality rates.