Clinical effect of enoxaparin on international normalized ratio following hepato-pancreatico-biliary and gastroesophageal resection.

BACKGROUND AND OBJECTIVES: Enoxaparin inactivates factor Xa via a complex formed after binding to circulating anti-thrombin III. This mechanism is reported not to alter hemostatic measures such as clotting time, PT, or PTT. To date, no clinical trials have shown a causal relationship between the clinical/pharmacological effects of enoxaparin on international normalized ratio (INR). The aim of our study is to show the clinical effect of enoxaparin on INR. METHODS: Patients (N = 350) were reviewed from our prospective IRB approved databases undergoing gastroesophageal or hepatobiliary surgeries. INR levels were recorded for 6 days: pre-operative to 5 days after surgery. RESULTS: Patients (N = 289) received enoxaparin daily starting post-operative day 1, while 61 patients who did not receive enoxaparin were used as controls. The mean post-operative INR in both the 30 and 40 mg groups were both significantly higher than the mean post-operative INR of the control group (P = 0.015 and P = 0.00075, respectively); however postoperative hemoglobin levels were not significantly lower in the enoxaparin versus control. CONCLUSION: This is the first clinical evidence of the effect of enoxaparin on INR in patients undergoing abdominal surgeries for malignancies. We demonstrate an increase in the INR for patients who received enoxaparin for post-operative VTE prophylaxis.

Development of the 12-Item Facial Complaints Evaluation Scale (FaCES-12).

OBJECTIVES: Chronic rhinosinusitis and related rhinologic disorders are common in routine otolaryngologic practice. Common presenting symptoms include nasal obstruction, facial pain, facial pressure, headache, and a subjective feeling of the face feeling "swollen," a perceptual distortion. No validated scale exists to assess facial pain in addition to perceptual distortion or headache. The objective was to develop a novel scale for assessment of facial symptoms experienced by patients presenting for rhinologic evaluation. METHODS: This was a prospective validation cross-sectional study. A patient questionnaire, the 12-item Facial Complaints Evaluation Scale (FaCES-12), was created to evaluate facial symptoms based on clinical experience and the literature, including severity and timing of facial pain, facial pressure, facial perceptual swelling, and headache. Each item was assessed utilizing an 11-point Likert scale ranging from 0 to 10 in severity. Data was collected prospectively from 210 patients in 1 private and 2 academic otolaryngologic practices from August to December 2019 along with the PROMIS Pain Intensity Scale 3a and 22-Item Sino-nasal Outcome Test. Construct validity was determined using Pearson correlation and exploratory factor analysis. Internal consistency and test-retest reliability were assessed by calculating Cronbach's alpha and assessing test-retest scores. RESULTS: A new 12-item scale named FaCES-12 was developed. FaCES-12 demonstrated high reliability with a Cronbach's alpha of .94 and high test-retest reliability (r = .90). The scale revealed very strong correlation with the PROMIS Pain Intensity Scale 3a (r = .81) and moderate correlation with the Sino-nasal Outcome Test (r = .48). Exploratory factor analysis demonstrated the scale contained interrelated variables that measured unique components of facial sensations. CONCLUSION: The FaCES-12 is a valid and reliable instrument for use in the evaluation of facial symptoms. Further research into the application of this scale is warranted.

A Throwing Knife Injury to the Neck: Management of a Unique Airway Situation.

Penetrating neck injuries (PNIs) can present as a simple wound or can be complicated by a disruption of the airway or associated vasculature. As such, stabilization of the vasculature and the airway is paramount. Here we present a case in which a hemodynamically stable 28-year-old female presents with a PNI involving the oropharynx and laryngopharynx.

Squamous Cell Carcinoma Originating from a Crohn's Enterocutaneous Fistula.

Purpose. Squamous cell carcinoma (SCC) developing within fistulae and chronic wounds in patients with Crohn's disease is a rare phenomenon with few reported studies in the literature. Clinical suspicion for SCC in Crohn's disease patients with chronic painful fistulae is low, leading to delayed diagnosis and treatment. We present a patient with long-standing Crohn's disease complicated by malignant degeneration of an enterocutaneous fistula tract. Methods. Workup with MRI, CT, and fistulogram revealed a 7 × 3 cm fistulous connection between a loop of small intestine and the patient's perineum. Biopsies of the fistula tract confirmed the diagnosis of SCC. Results. The patient underwent an abdominoperineal resection with positive margins and is currently awaiting radiation therapy. Conclusions. This is the second case reported within the English literature of SCC arising from an enterocutaneous fistula in the setting of Crohn's disease. Based on the findings in this case report and others presented in the literature, a high degree of suspicion of malignancy should be present in patients with chronic painful, poor-healing fistulae, especially in the absence of infection.

Permanent Loss of Preoperative Independence in Elderly Patients Undergoing Hepatectomy: Key Factor in the Informed Consent Process.

PURPOSE: Major (>3 segments of the liver) or minor hepatectomy has been demonstrated to provide the most definitive chance for long-term remission and disease-free survival in hepatic malignancies. However, concerns remain in regards to the ability of the elderly (>70 years old) and older (>80 years old) patients to "tolerate" this type of resection. Thus, the aim of this study was to determine the short- and long-term effects of hepatectomies in the elderly patient population. METHODS: An Institutional Review Board approved a prospectively maintained, single-institution HPB database with 663 consecutive hepatectomies from 2003 to 2013 was reviewed. Patients were separated into elderly (>70 years old) and older. Short-term effects were defined as a 30-day morbidity/mortality, and long-term effects were defined as a 90-day morbidity/mortality and the ability to regain preoperative functional independence. Comorbidities were compared using the Charleston Comorbidity Index (CCI). The log-rank and Wilcoxon tests were used to evaluate postoperative outcomes. RESULTS: A total of 663 patients were reviewed, 480 < 70y/o, 183 were 70 or older, 104 were 75 or older, and 41 were 80 or older. Patients over 70, 75, and 80 years of age showed a higher incidence of preoperative comorbidities than younger patients when compared using CCI (P < 0.05). Non-elderly patients had more liver lesions than elderly patients (median numbers only 3 vs. 1, P = 0.005). Patients over 70, 75, and 80 years old showed a higher 90-day mortality rate patients (11, 13, 17 %, respectively) to patients less than 70, 75 and 80 (3, 5, 5 %, respectively, P < 0.05) (Table). Patients over 70, 75, and 80 years old showed increased morbidity (53, 57, 66 %, respectively) than patients less than 70, 75, and 80 (39, 34, 41 %, respectively, P < 0.05). The severity of complication in elderly patients was similar to younger patients. Patients older than 70, 75, and 80 years showed an increased incidence of discharge to rehabilitation facilities (13, 15, 17 %, respectively) than patients less than 70, 75, and 80 (2, 3, 5 %, respectively, P = <0.001). Logistic regression demonstrated a significant risk of morbidity with an inability to return to preoperative function with a CCI > 5, major hepatectomy, and >75 years of age (HR 3.8, CI 2.1-5.6) CONCLUSIONS: This study demonstrates an increased rate of a 30- and 90-day postoperative mortality in >75-year old patients. Permanent loss of preoperative function (i.e., ability to live independently or alone) remains a significant risk and a subset of older patients. Communicating this loss of function as well as morbidity/mortality is key to the informed consent process for older patients as well as their families.