Esophageal adenocarcinoma and urothelial carcinoma orbital metastases masquerading as infection.

Orbital metastases can masquerade as other orbital processes. We present two cases of orbital metastases, the first being the first reported adenocarcinoma of the esophagus presenting as an orbital metastasis prior to the primary being known, and the other as the first urothelial carcinoma to present as orbital cellulitis. The first patient presented with left upper eyelid pain. CT scan identified a superolateral subperiosteal fluid collection without concomitant sinus disease, which was drained in the operating room. Two weeks later repeat CT scan showed recurrent orbital subperiosteal fluid. It was drained and a biopsy showed necrotic adenocarcinoma. The second case presented with a painless right proptosis, decreased vision, and globally decreased ocular motility 3 days after bladder resection for urothelial carcinoma. CT scan demonstrated pan sinusitis with a soft tissue mass in the apex of the right orbit with extension through the superior orbital fissure. After no improvement on antibiotics endoscopic drainage was performed. Pathology revealed metastatic urothelial carcinoma within the orbital fat.

Orbital cellulitis complicated by central retinal artery occlusion.

The authors present a case of a 16-year-old boy who sought treatment in Storm Eye Institute for orbital cellulitis complicated by central retinal artery occlusion. He was examined for severe signs of orbital cellulitis, including decreased vision and an afferent pupillary defect. Intravenous antibiotics failed to provide timely improvement, and the patient was surgically managed with endoscopic orbital decompression. An ocular examination under anesthesia revealed retinal ischemia in the affected eye, and fluorescein angiography confirmed the diagnosis of central retinal artery occlusion. The patient's vision improved slightly following resolution of the infection. Central retinal artery occlusion is a rare complication of orbital cellulitis in adults and has yet to be reported in the pediatric population.

Having Outpatient Major Elective (HOME) Robotic Colon Resection Protocol: A Safe Approach to Ambulatory Colon Resection.

BACKGROUND: Within the past decade, colorectal surgery length of stay (LOS) has decreased from an average of 5-6 days to 2-3 days. However, elective colon resections have yet to become a common procedure with the potential for same-day discharge. During the COVID pandemic, hospital capacity was exceptionally strained and colon resections were delayed due to the lack of inpatient beds available. PURPOSE: We sought to create a protocolized ERAS (enhanced recovery after surgery) pathway that would allow for safe and feasible ambulatory colon resections as well as decreasing overall hospital inpatient burden. RESEARCH DESIGN: Between November 2020 and March 2022, 15 patients were offered same-day discharges under the HOME protocol. Of the 15 patients, 11 patients agreed to be discharged home the day of surgery and followed prospectively for 30 days. All procedures were performed robotically. STUDY SAMPLE: Patients were selected based on level of preoperative health (ASA class 1 and 2), low-risk for loss to follow-up, ability for close family supervision for 3 days postoperatively, and type of procedure (partial colectomy). Close follow-up was achieved with daily telephonic or televideo visits for 3 days post-operatively, as well as a 2-week outpatient clinic follow-up. DATA COLLECTION: A total of 11 patient underwent same-day surgery utilizing the protocol, 5 females and 6 males, between the ages of 34 and 62. All patients were ASA class 2. Indications for colon resection were cecal volvulus (1), recurrent sigmmoid diverticulitis (9), and Crohn's disease (1). Primary outcome was readmission rates within the 30-days. RESULTS: There were no readmissions or complications during the perioperative 30-day period. There was one emergency department return for pain who was not admitted. Average operative time was 132.1 minutes. CONCLUSION: Using a novel enhanced recovery protocol, we demonstrated the feasibility and safety of ambulatory partial colectomy in a highly select small subset of patients.

Continuous positive airway pressure (CPAP) changes in bariatric surgery patients undergoing rapid weight loss.

BACKGROUND: Obstructive sleep apnea (OSA) is a common condition in morbidly obese patients, with the reported prevalence ranging from 12-78%. There is increasing recognition of the need to diagnose and treat/manage OSA both preoperatively and postoperatively. Nasal CPAP is the preferred treatment of OSA; however, weight loss is associated with a reduction in required pressures. We evaluated the CPAP pressure requirements in a group of patients undergoing rapid weight loss following Roux-en-Y gastric bypass. METHODS: 15 patients who had been diagnosed with OSA before surgery were retrospectively evaluated. All patients had demonstrated compliance on home CPAP therapy, were minimally 3 months post-surgery and had follow-up reports that their CPAP was less effective. We obtained data on age, sex, weight, BMI, and apnea/hypopnea index (AHI). Optimal CPAP pressure was obtained initially through attended in-laboratory complex polysomnography. Follow-up CPAP pressure was obtained using an auto-titrating PAP device at home. These data were used to evaluate the pressure changes that accompanied weight loss. RESULTS: This group of patients had lost an average of 44.5 +/- 19.4 kg. Four patients had achieved their goal weight. Their starting CPAP pressures averaged 11 +/- 3.0 cm H2O, with a range of 7-18 cm H2O. Follow-up CPAP pressures averaged 9 +/- 2.7 cm H2O, with a range of 4-12 cm H2O, representing an overall reduction of 18%. The subgroup of patients who had achieved goal weight had a pressure reduction of 22% (9 +/- 2.0 to 7 +/- 1.0 cm H2O). CONCLUSION: CPAP pressure requirements change considerably in bariatric surgery patients undergoing rapid weight loss. Auto-titrating PAP devices have promise for facilitating the management of CPAP therapy during this time. Consideration should also be given to the use of autotitrating PAP units as the treatment of choice in these patients.

Temporary abdominal closure followed by definitive abdominal wall reconstruction of the open abdomen.

BACKGROUND: Inability to close the abdominal wall after laparotomy for trauma may occur as a result of visceral edema, retroperitoneal hematoma, use of packing, and traumatic loss of tissue. Often life-saving, decompressive laparotomy and temporary abdominal closure require later restoration of anatomic continuity of the abdominal wall. METHODS: The trauma registry, open abdomen database, and patient medical records at a level 1 university-based trauma center were reviewed from January 1988 to December 2001. RESULTS: During the study period, more than 15,000 trauma patients were admitted, with 88 patients (0.6%) requiring temporary abdominal closure (TAC). Patients ages ranged from 12 to 75 years with a mean injury severity score (ISS) of 28 (range 5 to 54). Forty-five patients (51%) suffered penetrating injuries, and 43 (49%) were victims of blunt trauma. Indications for TAC included visceral edema in 61 patients (70%), abdominal compartment syndrome in 10 patients (11%), traumatic tissue loss in 9 patients (10%), and wound sepsis and fascial necrosis in 8 patients (9%). Fifty-six patients (64%) underwent TAC at admission laparotomy, whereas 32 patients (36%) required TAC at reexploration. Seventy-one patients (81%) survived and 17 (19%) died. Of the survivors, 24 patients (34%) underwent same-admission direct fascial closure, and 47 patients (66%) required visceral skin grafting and readmission closure. Reconstructive procedures in the patients requiring skin graft excision included direct fascial repair (20 patients, 44%), components separation closure with or without subfascial tissue expansion (18 patients, 40%), pedicled or free-tissue flaps (4 patients, 8%), and mesh repair (4 patients, 8%). One patient refused closure. The mean follow-up was 48 months (range 6 to 144), with an overall recurrence rate of 15% (range 10% to 50%), highest in the mesh repair group. CONCLUSIONS: Silicone sheeting TAC provides a safe and reliable temporary abdominal closure allowing for later definitive reconstruction. Direct fascial repair or components separation closure with or without tissue expansion can be utilized in the majority of patients for definitive reconstruction with low recurrence rate.