Predictors of Length of Hospital Stay After Reduction of Internal Hernia in Patients With a History of Roux-en-Y Gastric Bypass.

BACKGROUND: Postoperative internal hernias after Roux-en-Y gastric bypass (RYGB) have an incidence of 2%-9% and are a surgical emergency. Evidence on factors associated with length of stay (LOS) after emergent internal hernia reduction in RYGB patients is limited. METHODS: This is a retrospective review of patients who underwent internal hernia reduction after RYGB at our tertiary care center over a 5 year period from 2015 to 2020. Demographics, comorbidities, and intra- and postoperative hospital course were collected. Univariate and multivariate linear regressions were used to investigate factors associated with LOS. RESULTS: We identified 38 patients with internal hernia after RYGB. These patients with mean age 44.1 years were majority female (71.1%) and white race (60.5%). Of the 24 patients where the RYGB was done at our institution, the mean RYGB to IH interval was 43 months. Petersen's defect (57.8%) followed by jejuno-jejunal mesenteric defect (31.6%) were the most common locations for IH. Both Petersen's and jejuno-jejunal mesenteric hernias were found in 4 cases (10.5%). Revision of bypass and small bowel resection were required in 13.2% and 5.3% of cases, respectively. The median (interquartile range) length of stay (LOS) was 2 days. On the multivariate analysis, male sex (P = .019), conversion to exploratory laparotomy (P = .005), and resection of small bowel (P < .001) were independent risk factors for increased LOS. CONCLUSION: The most common location of IH after RYGB is Petersen's defect, followed by jejuno-jejunal mesenteric defect. LOS was significantly associated with male sex, exploratory laparotomy, and resection of small bowel.

Complications 18 years after polyacrylamide hydrogel augmentation mammoplasty: a case report and histopathological analysis.

Polyacrylamide hydrogel (PAAG) is a synthetic substance previously used as an injectable material for augmentation mammoplasty. Current literature has demonstrated that the average time from PAAG injection to the onset of complication ranges from 6 to 39 months. We present a unique case report describing the onset of complications 18 years after PAAG augmentation mammoplasty. To the best of our knowledge, the presentation of a healthy female who experienced unprovoked expansion of breast tissue >15 years after polyacrylamide injection has not been previously reported in surgical literature. This suggests that serious complications of PAAG injection may occur later than the literature has previously described. Importantly, this case is the first demonstration of the successful surgical removal of polyacrylamide 18 years after injection. Additionally, this case also provides a histopathological analysis of breast capsules which showed evidence of an extensive chronic inflammatory reaction to polyacrylamide, consistent with previous reports.

A rare case of percutaneous endoscopic gastrostomy causing a small bowel obstruction and subsequent bowel erosion.

Gastrostomy tubes can be used to provide long-term nutrition and feeding when oral intake is not adequate. A rare but serious complication includes iatrogenic small bowel injury. The incidence of this is infrequent due to its position of the small bowel beneath the omentum, however, injury leading to obstruction and volvulus has been previously described in the literature. We present an unusual case of gastrostomy tube transection into omental fat causing a kink in the small bowel allowing for a transition point of obstruction and subsequent erosion of the gastrostomy tube into the small bowel.

Climatic Impact of Volcanic Eruptions.

Volcanic eruptions have the potential to force global climate, provided they are explosive enough to emit at least 1-5 megaton of sulfur gases into the stratosphere. The sulfuric acid produced during oxidation of these gases will both absorb and reflect incoming solar radiation, thus warming the stratosphere and cooling the Earth's surface. Maximum global cooling on the order of 0.2-0.3°C, using instrumental temperature records, occurs in the first 2 years after the eruption, with lesser cooling possibly up to the 4th year. Equatorial eruptions are able to affect global climate, whereas mid- to high-latitude events will impact the hemisphere of origin. However, regional responses may differ, including the possibility of winter warming following certain eruptions. Also, El Niño warming may override the cooling induced by volcanic activity. Evaluation of different style eruptions as well as of multiple eruptions closely spaced in time beyond the instrumental record is attained through the analysis of ice-core, tree-ring, and geologic records. Using these data in conjunction with climate proxy data indicates that multiple eruptions may force climate on decadal time scales, as appears to have occurred during the Little Ice Age (i.e., roughly AD 1400s-1800s). The Toba mega-eruption of ~75,000 years ago may have injected extremely large amounts of material into the stratosphere that remained aloft for up to about 7 years. This scenario could lead to the initiation of feedback mechanisms within the climate system, such as cooling of sea-surface temperatures. These interacting mechanisms following a mega-eruption may cool climate on centennial time scales.