RESUMO
Cardiac injuries following blunt trauma are rare but potentially lethal in children. We present a 23-month-old child who sustained an aneurysm of the left ventricle free wall and ventricular septum with associated ventricular septal defect following blunt trauma. She underwent successful surgical repair 6 weeks following her date of injury. Surgical decision-making surrounding this case is discussed.
Assuntos
Aneurisma Cardíaco , Traumatismos Cardíacos , Comunicação Interventricular , Septo Interventricular , Ferimentos não Penetrantes , Criança , Pré-Escolar , Feminino , Aneurisma Cardíaco/diagnóstico por imagem , Aneurisma Cardíaco/etiologia , Aneurisma Cardíaco/cirurgia , Traumatismos Cardíacos/diagnóstico por imagem , Traumatismos Cardíacos/etiologia , Traumatismos Cardíacos/cirurgia , Comunicação Interventricular/diagnóstico por imagem , Comunicação Interventricular/cirurgia , Humanos , Lactente , Septo Interventricular/diagnóstico por imagem , Septo Interventricular/cirurgia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgiaRESUMO
Robotic-assisted surgery has become a desired modality for performing colectomy; however, unplanned conversion to an open procedure may be associated with worse outcomes. The purpose of this study is to examine predictors and consequences of unplanned conversion to open in a large, high fidelity data set. A retrospective analysis of 11 061 robotic colectomies was conducted using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) 2012-2017 database. Predictors of conversion and the effect of conversion on outcomes were analyzed by multivariate logistic regression resulting in risk-adjusted odds ratios of conversion and morbidity/mortality. Overall, 10 372 (93.8%) patients underwent successful robotic colectomy, and 689 (6.2%) had an unplanned conversion. Predictors of conversion included age ≥ 65 years, male gender, obesity, functional status not independent, American Society of Anesthesia (ASA) classification IV-V, non-oncologic indication, emergency case, smoking, recent weight loss, bleeding disorder, and preoperative organ space infection. Conversion is an independent risk factor for mortality, overall morbidity, cardiac morbidity, pulmonary morbidity, renal morbidity, venous thromboembolism morbidity, wound morbidity, sepsis, bleeding, readmission, return to the operating room, and extended length of stay (LOS). Unplanned conversion to open during robotic colectomy is an independent predictor of morbidity and mortality.
Assuntos
Procedimentos Cirúrgicos Robóticos , Idoso , Colectomia/efeitos adversos , Colectomia/métodos , Humanos , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Melhoria de Qualidade , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Estados UnidosRESUMO
The effect of energy devices, nerve monitors, and drains on thyroidectomy outcomes has been examined for each tool independently. Current literature supports the routine use of energy devices and nerve monitors and does not support the routine use of drains. The effect of these operative tools is interrelated and should be examined concurrently. The aim of this study was to describe the risk-adjusted effect of each of these tools on thyroidectomy outcomes. A retrospective analysis of 17 985 open thyroidectomy procedures was conducted using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) 2016-2018 thyroidectomy targeted procedure database. All open thyroidectomies were included. The risk-adjusted effect of energy devices, nerve monitors, and drains on 30-day outcomes was calculated by multiple logistic regression. Energy devices were associated with a decreased risk of hematoma and decreased extended length of stay without increased risk of hypocalcemia or recurrent laryngeal nerve injury. Nerve monitors were associated with a decreased risk of overall morbidity, decreased recurrent laryngeal nerve injury, and decreased extended length of stay without an increased risk of adverse outcomes. Drains were associated with an increased risk of bleeding, reoperation, and extended length of stay without decreasing hematoma. Our results support the routine use of energy devices and nerve monitors for thyroidectomy and do not support the routine use of drains for thyroidectomy.
Assuntos
Traumatismos do Nervo Laríngeo Recorrente , Cirurgiões , Hematoma/complicações , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Melhoria de Qualidade , Traumatismos do Nervo Laríngeo Recorrente/complicações , Estudos Retrospectivos , Tireoidectomia/efeitos adversos , Tireoidectomia/métodos , Estados UnidosRESUMO
BACKGROUND: Anatomic lung resection (ALR) outcomes are superior for cardiothoracic surgeons (CTSs) by analysis of Medicare; National Inpatient Sample; South Carolina Office of Research and Statistics; and Surveillance, Epidemiology, and End Results databases. Similar findings have been reported for all noncardiac thoracic procedures using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Our aim was to further delineate outcome differences between CTSs and general surgeons (GSs) specifically for ALR. METHODS: A retrospective analysis of 15,574 nonemergent, nonpediatric ALR for lung cancer was conducted using the ACS-NSQIP 2013 to 2017 database. Included procedures were all ALR for lung cancer. Surgeons were classified as CTSs or GSs. Other specialties were excluded. Preoperative characteristics and 30-day outcomes were compared by bivariate (chi-square test) and multivariate analysis. Multivariate analysis was conducted by multiple logistic regression. RESULTS: CTSs performed 14,172 (91.0%) of included procedures, and GSs performed 1402 (9.0%). A thoracoscopic approach was utilized at a similar rate (49.08% for CTSs vs 49.71% for GSs; P = .747). The extent of resection differed in a statistically, but not clinically, significant fashion. CTS patients had a higher rate of preoperative dyspnea (22.66% for CTSs vs 17.62% for GSs; P < .001). Procedures performed by CTSs had a lower risk-adjusted odds ratio of overall morbidity, pulmonary morbidity, sepsis or septic shock, bleeding requiring transfusion, and length of stay greater than the median (5 days). CONCLUSIONS: ALR outcomes are superior for CTSs when compared with GSs. This is consistent with prior studies looking at this specific subset of patients and studies looking at a different subset of patients using the ACS-NSQIP database.
Assuntos
Competência Clínica , Neoplasias Pulmonares/cirurgia , Pneumonectomia/métodos , Melhoria de Qualidade , Cirurgiões/normas , Idoso , Feminino , Humanos , Masculino , Estudos RetrospectivosRESUMO
BACKGROUND: Recurrent laryngeal nerve (RLN) injury is a serious complication of thyroidectomy. The purpose of this study is to determine the predictors and consequences of RLN injury during thyroidectomy. METHODS: A retrospective analysis was conducted using the ACS-NSQIP 2016-2017 main and thyroidectomy targeted procedure databases. Data was analyzed by multivariate logistic regression resulting in risk-adjusted odds ratios of RLN injury and morbidity/mortality. RESULTS: Age ≥65, black race, neoplastic indication, total or subtotal thyroidectomy, concurrent neck surgery, operation time > median, hypoalbuminemia, and anemia were associated with RLN injury. Use of intraoperative nerve monitoring was associated with decreased RLN injuries. RLN injury is a risk factor for overall morbidity, hypocalcemia, hematoma, pulmonary morbidity, readmission, reoperation, and length of stay > median. CONCLUSION: Several predictors of RLN injury during thyroidectomy are identified, while use of intraoperative nerve monitoring was associated with a decreased risk of RLN injury. RLN injury is associated increased postoperative complications.
Assuntos
Complicações Intraoperatórias , Traumatismos do Nervo Laríngeo Recorrente , Tireoidectomia , Idoso , Bases de Dados Factuais , Feminino , Previsões , Cirurgia Geral , Humanos , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/prevenção & controle , Masculino , Melhoria de Qualidade , Traumatismos do Nervo Laríngeo Recorrente/epidemiologia , Traumatismos do Nervo Laríngeo Recorrente/etiologia , Estudos Retrospectivos , Sociedades Médicas , Tireoidectomia/métodos , Tireoidectomia/normas , Estados UnidosRESUMO
BACKGROUND: Hematoma after thyroid surgery is a serious complication. The purpose of this study was to determine the predictors and consequences of hematoma after thyroid surgery. MATERIALS AND METHODS: A retrospective analysis of 11,552 open thyroidectomies was conducted using the American College of Surgeons National Surgical Quality Improvement Program 2016-2017 main and thyroidectomy-targeted procedure databases. Predictors of hematoma and the effect of hematoma on outcomes were analyzed by multivariate logistic regression, resulting in risk-adjusted odds ratios of hematoma and morbidity/mortality, respectively. Statistical analysis was performed using R version 3.5.1. RESULTS: We found that male gender (odds ratio 1.71, 95% confidence interval 1.25-2.32; P value 0.0007), Black race (1.89, 1.27-2.77; 0.0014), other race (1.76, 1.23-2.50; 0.0017), hypertension (1.68, 1.20-2.35; 0.0026), diabetes (1.45, 1.00-2.06; 0.0460), and bleeding disorders (3.63, 1.61-7.28; 0.0007) were independent risk factors for postoperative hematoma. The use of an energy device for hemostasis (0.63, 0.46-0.87; 0.0041) was independently associated with decreased hematoma rate. Postoperative hematoma was an independent risk factor for overall morbidity (3.04, 2.21-4.15; <0.0001), hypocalcemia (1.73, 1.08-2.66, 0.0162), recurrent laryngeal nerve injury (2.42, 1.57-3.60, <0.0001), pulmonary morbidity (18.91, 10.13-34.16, <0.0001), wound morbidity (10.61, 5.54-19.02, <0.0001), readmission (5.23, 3.34-7.92, <0.0001), return to operating room (90.73, 62.62-131.97; <0.0001), and length of stay greater than the median (5.10, 3.62-7.15, <0.0001). CONCLUSIONS: Identified by this study are the predictors of postthyroidectomy hematoma and the consequences thereof. Notably, the use of energy devices for hemostasis was shown to be protective of postoperative hematoma. The results of this study may guide pre- and intra-operative decision-making for thyroidectomy to reduce rates of postoperative hematoma.
Assuntos
Hematoma/etiologia , Complicações Pós-Operatórias/etiologia , Tireoidectomia , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Hematoma/epidemiologia , Hematoma/prevenção & controle , Hemostasia Cirúrgica/instrumentação , Hemostasia Cirúrgica/métodos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Fatores de Proteção , Estudos Retrospectivos , Risco Ajustado , Fatores de Risco , Estados UnidosRESUMO
BACKGROUND: Utilization of robotic-assistance for esophagectomy is increasing. The differences in outcomes between robotic-assisted minimally-invasive esophagectomy (RAMIE) and non-robotic minimally-invasive esophagectomy (MIE) for esophageal cancer are unknown. The purpose of this study was to compare 30-day postoperative outcomes between RAMIE and MIE. METHODS: A retrospective analysis was conducted using the ACS-NSQIP 2016-2017 databases. Primary outcome was 30-day postoperative mortality and morbidity. RESULTS: 725 minimally-invasive cases were identified, which included 100 RAMIE and 625 MIE. RAMIE was not found to be a risk factor for postoperative mortality (OR 1.50, 95% CI 0.38-6.00, pâ¯=â¯0.5675) or overall morbidity (OR 0.65, 95% CI 0.40-1.06, pâ¯=â¯0.0818). No significant differences were found between groups for systemic, organ-specific, or surgical complications. CONCLUSIONS: No significant difference was found in the incidence of 30-day postoperative outcomes between RAMIE and MIE. In comparison to MIE, RAMIE may be considered a feasible but non-superior option for treatment of esophageal cancer.
Assuntos
Neoplasias Esofágicas/cirurgia , Esofagectomia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos , Avaliação de Processos e Resultados em Cuidados de Saúde , Procedimentos Cirúrgicos Robóticos , Idoso , Bases de Dados Factuais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
Pain from traumatic rib fractures presents a source of major morbidity and mortality. Prior studies have reported 59% of patients continue to have persistent pain at 2â¯months post injury. Most modern analgesia modalities have short duration of effect (<72â¯h) and require repeated doses to achieve adequate effect. There are few studies that address long-term analgesia treatment for these injuries. Intercostal cryoneurolysis (IC) is a technique of long-term chest wall analgesia previously studied in thoracic surgery and pediatric chest wall reconstruction. This technique may also be an effective treatment for rib fracture pain. Presented is a case of successful control of rib fracture pain with IC used as an adjunct to surgical stabilization of rib fractures (SSRF). This is followed by a discussion of IC's role in the treatment of traumatic rib fracture pain.
RESUMO
BACKGROUND: The advent of robotic-assisted surgery has added an additional decision point in the treatment of inguinal hernias. The goal of this study was to identify the patient, surgeon, and hospital demographic predictors of robotic inguinal hernia repair (IHR). METHODS: We conducted a retrospective analysis of 102,241 IHRs (1096 robotic and 101,145 laparoscopic) from 2010 through 2015 with data collected in the Premier Hospital Database. The adjusted odds ratio (OR) of receiving a robotic IHR was calculated for each of several demographic factors using multivariable logistic regression. RESULTS: The rate of robotic IHR increased from 2010 through 2015. Age <65 y and Charlson comorbidity index were not predictors of a robotic IHR. Females were more likely to receive a robotic IHR (OR 1.69, confidence interval [CI] 1.40-2.05, P < 0.0001). Compared with white patients, black patients were more likely (OR 1.33, CI 1.06-1.68, P = 0.0138), and other race patients were less likely (OR 0.47, CI 0.38-0.58, P < 0.0001) to receive a robotic IHR. Compared with Medicare insurance, patients with all other types of insurance were more likely to receive a robotic IHR (OR > 1.00, lower limit of CI > 1.00, P < 0.05). Higher volume surgeons were less likely to perform robotic IHR (OR < 1.00, upper limit of CI < 1.00, P < 0.05). Nonteaching (OR 1.81, CI 1.53-2.13, P < 0.0001), larger (OR > 1.00, lower limit of CI > 1.00, P < 0.05), and rural (OR 1.27, CI 1.03-1.57, P = 0.025) hospitals were more likely to perform robotic IHR. Significant regional variation in the rate of robotic IHR was identified (OR > 1.00, lower limit of CI > 1.00, P < 0.05). CONCLUSIONS: The rate of robotic IHR is increasing exponentially. This study found that female gender, black race, insurance other than Medicare, lower surgeon annual volume, larger hospital size, nonteaching hospital status, rural hospital location, and hospital region were predictors of robotic IHR.
Assuntos
Hérnia Inguinal/cirurgia , Herniorrafia/estatística & dados numéricos , Seleção de Pacientes , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Negro ou Afro-Americano/estatística & dados numéricos , Idoso , Feminino , Herniorrafia/economia , Herniorrafia/tendências , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Humanos , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/tendências , Fatores Sexuais , Cirurgiões/estatística & dados numéricos , Estados Unidos , Carga de Trabalho/estatística & dados numéricosRESUMO
Pulmonary blastoma is a rare, aggressive neoplasm accounting for less than 1% of lung cancers in adults. Reported is a case of pulmonary blastoma in an adult with the unusual presentation of hemoptysis followed by large hemothorax. The patient received a lobectomy. Pathologic examination showed clear resection margins without nodal involvement. However, the patient developed recurrence 4 months postoperatively and died shortly thereafter. The clinical characteristics of pulmonary blastoma are discussed.
Assuntos
Hemoptise/etiologia , Hemotórax/etiologia , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/diagnóstico , Blastoma Pulmonar/complicações , Blastoma Pulmonar/diagnóstico , Idoso , Feminino , Humanos , Neoplasias Pulmonares/cirurgia , Blastoma Pulmonar/cirurgiaRESUMO
BACKGROUND: Inguinal hernia repair (IHR) is among the most common general surgery procedures. Multiple studies have examined costs and benefits of laparoscopic approach versus open repair. This study aimed to identify patient, surgeon, and hospital demographic predictors of laparoscopic versus open IHR. METHODS: We conducted a retrospective analysis of 342,814 IHRs (241,669 open; 101,145 laparoscopic) performed in adults (age ≥ 18) from 2010 to 2015 using the Premier Hospital Database. Multivariate logistic regression was used to estimate the adjusted odds ratio of an IHR being laparoscopic versus open with respect to several demographic variables. RESULTS: The odds of an IHR being laparoscopic increased from 2010 to 2015. A laparoscopic procedure was more likely in patients who were < age 65 (OR 1.29, CI 1.24-1.31, p < 0.0001), male (OR 1.31, CI 1.27-1.34, p < 0.0001), privately insured (OR 1.36, CI 1.33-1.40, p < 0.0001), and neither white, black, nor Hispanic (OR 1.11, CI 1.09-1.14, p < 0.0001). The likelihood of a procedure being laparoscopic decreased 13% with each one-unit increase in Charlson comorbidity index value (OR 0.88, CI 0.87-0.89, p < 0.0001). Surgeons were more likely to perform a laparoscopic procedure if they had larger annual IHR caseloads (≥ 45/year; OR 1.57, CI 1.53-1.60, p < 0.0001), and operated at large hospitals (> 500 beds; OR 1.36, CI 1.33-1.39, p < 0.0001) in New England (OR 2.38, CI 2.29-2.47, p < 0.0001). Non-predictors of a laparoscopic procedure included urban/rural hospital location (OR 1.02, CI 0.10-1.05, p = 0.06) and hospital teaching status (OR 1.01, CI 0.99-1.03, p = 0.2084). CONCLUSIONS: Use of laparoscopic IHR is increasing. Patient age, gender, race, and insurance type, as well as surgeon annual volume, hospital size, and hospital region were predictors of a laparoscopic procedure. Further studies are needed to explain and remedy underlying differences impacting these predictors.
Assuntos
Hérnia Inguinal/cirurgia , Herniorrafia/métodos , Laparoscopia/métodos , Fatores Etários , Idoso , Bases de Dados Factuais , Feminino , Tamanho das Instituições de Saúde , Herniorrafia/estatística & dados numéricos , Hospitais Rurais , Hospitais Urbanos , Humanos , Cobertura do Seguro , Laparoscopia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Fatores Raciais , Estudos Retrospectivos , Fatores Sexuais , Estados UnidosAssuntos
Barotrauma/complicações , Doenças do Esôfago/etiologia , Manobra de Heimlich/efeitos adversos , Hemorragia/etiologia , Vômito/complicações , 2-Piridinilmetilsulfinilbenzimidazóis/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Barotrauma/etiologia , Tratamento Conservador , Meios de Contraste , Endoscopia do Sistema Digestório , Feminino , Gastrostomia , Humanos , Pantoprazol , Nutrição Parenteral , Inibidores da Bomba de Prótons/uso terapêutico , Tomografia Computadorizada por Raios XRESUMO
The long term efficacy of tissue based heart valve grafts may be limited by progressive degeneration characterized by immune mediated inflammation and calcification. To avoid this degeneration, decellularized heart valves with functionalized surfaces capable of rapid in vivo endothelialization have been developed. The aim of this study is to examine the capacity of CD133 antibody-conjugated valve tissue to capture circulating endothelial progenitor cells (EPCs). Decellularized human pulmonary valve tissue was conjugated with CD133 antibody at varying concentrations and exposed to CD133 expressing NTERA-2 cl.D1 (NT2) cells in a microflow chamber. The amount of CD133 antibody conjugated on the valve tissue surface and the number of NT2 cells captured in the presence of shear stress was measured. Both the amount of CD133 antibody conjugated to the valve leaflet surface and the number of adherent NT2 cells increased as the concentration of CD133 antibody present in the surface immobilization procedure increased. The data presented in this study support the hypothesis that the rate of CD133(+) cell adhesion in the presence of shear stress to decellularized heart valve tissue functionalized by CD133 antibody conjugation increases as the quantity of CD133 antibody conjugated to the tissue surface increases.
Assuntos
Anticorpos Monoclonais/imunologia , Antígenos CD/imunologia , Bioprótese , Células Progenitoras Endoteliais/imunologia , Glicoproteínas/imunologia , Próteses Valvulares Cardíacas , Peptídeos/imunologia , Valva Pulmonar/citologia , Antígeno AC133 , Linhagem Celular , Separação Celular/métodos , Sistema Livre de Células/imunologia , Sistema Livre de Células/patologia , Humanos , Valva Pulmonar/imunologiaRESUMO
Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital heart defect that usually presents before the age of 1 year. Several surgical options exist for the correction of ALCAPA; however, debate continues regarding the optimal repair technique in adult populations. We report the case of successful surgical repair of ALCAPA with a direct aortic implantation technique in a 44-year-old mother of 4 children.
Assuntos
Anomalias dos Vasos Coronários/cirurgia , Ecocardiografia Transesofagiana , Estenose da Valva Mitral/cirurgia , Artéria Pulmonar/anormalidades , Adulto , Anastomose Cirúrgica , Angiografia/métodos , Implante de Prótese Vascular/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/métodos , Terapia Combinada , Anomalias dos Vasos Coronários/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Cuidados Intraoperatórios/métodos , Estenose da Valva Mitral/diagnóstico por imagem , Cuidados Pré-Operatórios/métodos , Artéria Pulmonar/cirurgia , Doenças Raras , Medição de Risco , Esternotomia/métodos , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
Natural materials employ many elegant strategies to achieve mechanical properties required for survival under varying environmental conditions. Thus these remarkable biopolymers and nanocomposites often not only have a combination of mechanical properties such as high modulus, toughness, and elasticity, but also exhibit adaptive and stimuli-responsive properties. Inspired by skeletal muscle protein titin, we have synthesized a biomimetic modular polymer that not only closely mimics the modular multidomain structure of titin, but also manifests an exciting combination of mechanical properties, as well as adaptive properties such as self-healing and temperature-responsive shape-memory properties.