RESUMO
CASE SUMMARY: A 73-year-old woman, who had received apixaban for therapeutic anticoagulation, presented with hypotension and hematochezia. After resuscitation, diagnostic colonoscopy revealed multiple polyps and old blood within the colonic lumen, but no active bleeding (Fig. 1). Nasogastric lavage and subsequent EGD were unremarkable. During her hospitalization, she was admitted to the intensive care unit with worsening anemia, hypotension, and hematochezia. CT angiogram showed extravasation at the transverse colon (Fig. 1). Formal angiogram was unable to localize the source of bleeding, despite provocation. Given the localization on CT angiography and the patient's clinical deterioration, she underwent hand-assisted segmental transverse colectomy. Surgical pathology was notable for multiple adenomas without dysplasia. The patient had no further episodes of GI bleeding after resection.
Assuntos
Hemorragia Gastrointestinal , Hipotensão , Idoso , Colectomia , Colo/cirurgia , Colonoscopia , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Humanos , Hipotensão/cirurgiaRESUMO
Kidney transplantation entails well-coordinated complex care delivery. Patient-provider cultural and linguistic discordance can lead to healthcare disparities. We analyzed kidney transplantation outcomes among our institution's Hmong recipients using a retrospective cohort study. From 1995 to 2015, 2164 adult (age ≥18) recipients underwent kidney transplantation at our institution; 78 self-identified as Hmong. Survival rates were analyzed and compared to Caucasian recipients (n = 2086). Fifty (64.1%) Hmong recipients consistently requested interpreters. Mean follow-up was 9.8 years for both groups. Hmong recipients (N = 78) were on average younger at transplant (45.7 vs 49.7 years; P = 0.02), more likely to be female (56% vs 38%; P = 0.001), and had higher gravidity (5.0 vs 1.9 births; P < 0.001). There were 13 (16.7%) Hmong living donor recipients, who were younger (32.8 vs 42.9 years; P = 0.006) at transplant compared to Caucasians (1429, 68.5%). Hmong 1- and 5-year patient survival was 100%; Caucasians, 97.1% and 88% (P < 0.001). Hmong 1- and 5-year graft survival was 98.7% and 84.9%; Caucasians 94.8% and 80.9% (P = 0.013). One- and 5-year rejection-free survival showed no difference (88.9% vs 82.4%; 86.7% vs 83.4%, P = 0.996). Despite cultural and linguistic differences between Hmong recipients and providers, we found no evidence of inferiority in KT outcomes in the Hmong population.
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Atenção à Saúde , Etnicidade/estatística & dados numéricos , Rejeição de Enxerto/mortalidade , Disparidades em Assistência à Saúde/estatística & dados numéricos , Falência Renal Crônica/mortalidade , Transplante de Rim/mortalidade , Complicações Pós-Operatórias , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Rejeição de Enxerto/epidemiologia , Sobrevivência de Enxerto , Disparidades em Assistência à Saúde/tendências , Humanos , Incidência , Falência Renal Crônica/etnologia , Falência Renal Crônica/cirurgia , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Transplantados , Adulto JovemRESUMO
Hereditary pancreatitis (HP) is a progressive disease that can manifest in childhood with debilitating, relapsing pain. A total pancreatectomy and islet autotransplant (TPIAT) is a surgical option to relieve chronic pain while preserving the available ß-cell mass. The clinical course of HP is fraught with pancreatitis-related sequelae that can both necessitate and complicate a TPIAT. We describe a child with HP who developed a pancreatic pseudocyst-portal vein (PV) fistula. Active hemorrhage of the perforated PV into the pseudocyst and PV thrombosis complicated the planned TPIAT procedure and, preoperatively, required urgent image-guided stenting. During the TPIAT procedure, the endovascular stent was found to be protruding through the PV into the pseudocyst. Using the autologous splenic vein from the TPIAT specimen, we performed a vascular reconstruction of the perforated PV. This case underscores the need for evaluation of children with HP by a multidisciplinary pancreatic TPIAT care team to best prepare for the potential ramifications of pancreatitis-related complications. It also illustrates a useful vascular reconstruction technique for PV complications.
Assuntos
Transplante das Ilhotas Pancreáticas/métodos , Pancreatectomia/métodos , Pancreatite Crônica/terapia , Procedimentos de Cirurgia Plástica , Veia Porta/cirurgia , Veia Esplênica/cirurgia , Adolescente , Autoenxertos , Humanos , Masculino , PrognósticoRESUMO
The Organ Procurement Transplant Network (OPTN) listing criteria for simultaneous liver-kidney transplant (SLK) are not well defined. Concerns remain about rising numbers of SLKs, which divert quality kidneys from candidates awaiting kidney transplants (KT). We performed a retrospective review of liver transplants (LTs) at our center from 2004 to 2014; 127 recipients (liver transplant alone; 102 LTA, 25 SLK) were identified with short-term preoperative kidney dysfunction (creatinine >4 mg/dL or preoperative hemodialysis [HD] for <6 weeks). Both cohorts had comparable baseline demographic characteristics with the exception of higher model for end-stage liver disease (MELD) score in the LTA group (41.4 vs 32.9, P < .0001) and higher incidence of pre-LT diabetes in the SLK cohort (52% vs 26.5%, P = .0176). Duration of pre-LT HD was higher in SLK recipients, but the difference was not statistically significant (P = .39). Renal nonrecovery (RNR) rate in LTA cohort was low (<5%). No significant difference was noted in 1-year mortality, liver graft rejection/failure, or length of stay (LOS) between the cohorts. Thus, it appears that liver recipients with short-term (<6 weeks) HD or AKI without HD have comparable outcomes between LTA and SLK. With provisions for a KT safety net, as proposed by OPTN, LTA may be the most adequate option for these patients.
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Doença Hepática Terminal/mortalidade , Rejeição de Enxerto/mortalidade , Transplante de Rim/mortalidade , Transplante de Fígado/mortalidade , Complicações Pós-Operatórias , Insuficiência Renal/mortalidade , Adulto , Idoso , Doença Hepática Terminal/complicações , Doença Hepática Terminal/cirurgia , Feminino , Seguimentos , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/cirurgia , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Diálise Renal , Insuficiência Renal/etiologia , Insuficiência Renal/cirurgia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Obtenção de Tecidos e Órgãos , Adulto JovemRESUMO
The Rothman Index (RI) is a real-time health indicator score that has been used to quantify readmission risk in several fields but has never been studied in gastrointestinal surgery. In this retrospective single-institution study, the association between RI scores and readmissions after unplanned colectomy or proctectomy was evaluated in 427 inpatients. Patient demographics and perioperative measures, including last RI, lowest RI, and increasing/decreasing RI score, were collected. In the selected cohort, 12.4% of patients were readmitted within 30 days of their initial discharge. Last RI, lowest RI, decreasing RI, and increasing RI scores remained significant after controlling for covariates in separate multivariate regression analyses. The last RI score at the time of discharge was found to be the most strongly associated with 30-day readmission risk following colorectal resection. These findings support the RI as a potential tool in the inpatient management of postoperative patients to identify those at high risk of readmission.
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Neoplasias Colorretais , Readmissão do Paciente , Humanos , Estudos Retrospectivos , Colectomia , Fatores de Tempo , Fatores de Risco , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologiaRESUMO
BACKGROUND: Radiomics is an approach to medical imaging that quantifies the features normally translated into visual display. While both radiomic and clinical markers have shown promise in predicting response to neoadjuvant chemoradiation therapy (nCRT) for rectal cancer, the interrelationship is not yet clear. METHODS: A retrospective, single-institution study of patients treated with nCRT for locally advanced rectal cancer was performed. Clinical and radiomic features were extracted from electronic medical record and pre-treatment magnetic resonance imaging, respectively. Machine learning models were created and assessed for complete response and positive treatment effect using the area under the receiver operating curves. RESULTS: Of 131 rectal cancer patients evaluated, 68 (51.9%) were identified to have a positive treatment effect and 35 (26.7%) had a complete response. On univariate analysis, clinical T-stage (OR 0.46, p = 0.02), lymphovascular/perineural invasion (OR 0.11, p = 0.03), and statin use (OR 2.45, p = 0.049) were associated with a complete response. Clinical T-stage (OR 0.37, p = 0.01), lymphovascular/perineural invasion (OR 0.16, p = 0.001), and abnormal carcinoembryonic antigen level (OR 0.28, p = 0.002) were significantly associated with a positive treatment effect. The clinical model was the strongest individual predictor of both positive treatment effect (AUC = 0.64) and complete response (AUC = 0.69). The predictive ability of a positive treatment effect increased by adding tumor and mesorectal radiomic features to the clinical model (AUC = 0.73). CONCLUSIONS: The use of a combined model with both clinical and radiomic features resulted in the strongest predictive capability. With the eventual goal of tailoring treatment to the individual, both clinical and radiologic markers offer insight into identifying patients likely to respond favorably to nCRT.
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Terapia Neoadjuvante , Neoplasias Retais , Humanos , Terapia Neoadjuvante/métodos , Resultado do Tratamento , Estudos Retrospectivos , Imageamento por Ressonância Magnética , Neoplasias Retais/terapia , Neoplasias Retais/tratamento farmacológico , Aprendizado de MáquinaRESUMO
INTRODUCTION: Although histoplasmosis is an extremely rare cause of bowel obstruction, this case describes disseminated gastrointestinal histoplasmosis as it progresses from acute colitis to subacute recurrent bowel obstructions. CASE PRESENTATION: A White man in his early 80s with history of multiple myeloma presented to the emergency department with lightheadedness and diarrhea. Following a diagnostic journey for unspecified colitis, urine antigen testing and endoscopic biopsies led to the diagnosis. During the initial 12 weeks of antifungal treatment, the disease process transitioned from an acute inflammatory syndrome into a recurrent bowel obstruction. DISCUSSION/CONCLUSIONS: Only one other case of histoplasmosis causing recurrent bowel obstruction has been reported; however, that patient succumbed to the disease without surgical intervention. No clear guidelines exist of how to manage bowel obstructions from rare infectious sources, such as histoplasmosis, but close surveillance, multidisciplinary care, and an understanding of gastrointestinal pathology can guide clinicians when encountering atypical etiologies of bowel obstruction.
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Colite , Histoplasmose , Obstrução Intestinal , Masculino , Humanos , Histoplasmose/complicações , Histoplasmose/diagnóstico , Histoplasmose/tratamento farmacológico , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/etiologia , Obstrução Intestinal/patologia , Biópsia/efeitos adversosRESUMO
BACKGROUND: Current American Society of Colorectal Surgery Clinical Practice Guidelines for Ambulatory Anorectal Surgery endorse use of monitored anesthesia care, general anesthesia, or spinal anesthesia based on physician and patient preference. Although several studies support the use of monitored anesthesia care over general anesthesia, the literature regarding spinal anesthesia is limited and heterogenous due to small sample sizes and disparate spinal anesthesia techniques. Saddle block anesthesia is a form of spinal anesthesia that localizes to the lowermost sacral spinal segments allowing for preservation of lower extremity motor function and faster recovery. We accrued one of the largest reported cohort of anorectal procedures using saddle block anesthesia, as such, we sought to evaluate our institutional 12-year experience. METHODS: Patients who underwent a benign anorectal procedure at our outpatient surgery center between July 2008-2020 were retrospectively reviewed. Demographics, surgical factors, perioperative times, and adverse events were collected from the electronic medical records. Saddle block anesthesia was generally performed in the preoperative area using a spinal needle (25-27 gauge) and a single injection technique of a 1:1 ratio local anesthetic mixed with 10% dextrose solution. Between 2.5-5 mg of hyperbaric anesthetic was injected intrathecally in the sitting position and the patient remained upright for 3-10 minutes. This technique of saddle block anesthesia provides analgesia for approximately 1-3 hours. RESULTS: In the study, 859 saddle block anesthesia patients were identified, with a mean age of 44.6 years and American Society of Anesthesia score of 1.9; 609 (70.9%) were male. Surgical indications included lesion removal (27.1%), anal fistula (25.8%), hemorrhoidectomy (24.7%), pilonidal disease (6.3%), anal fissure (5.8%), and a combination of prior (10.2%). Prone jackknife positioning was used in 91.6% of procedures. Saddle block anesthesia most often was performed with bupivacaine (48.9%) or ropivacaine (41.7%). The median procedural saddle block anesthesia time was 11 minutes, surgery time was 17 minutes, anesthesia time was 42 minutes, and recovery time was 91 minutes. Patients spent a median of 3 hours and 53 minutes in the facility. Adverse events included urinary retention (1.9%), conversion to general anesthesia (1.8%), spinal headache (1.5%), hemodynamic instability (0.9%), and injection site reaction (0.3%). CONCLUSION: Demonstrated using the largest known cohort of anorectal patients with saddle block anesthesia, saddle block anesthesia provides an effective method of analgesia to avoid general anesthesia with a low rate of adverse events.
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Procedimentos Cirúrgicos Ambulatórios , Raquianestesia/métodos , Anestésicos Locais/administração & dosagem , Doenças Retais/cirurgia , Adulto , Bupivacaína/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Posicionamento do Paciente , Doenças Retais/patologia , Estudos Retrospectivos , Ropivacaina/administração & dosagemRESUMO
BACKGROUND: Bariatric surgery (BS) may be associated with significant malabsorption and nutritional deficiencies. METHODS: Between March 1987 and January 2017, we performed 922 liver transplants (LT) at our institution; 33 had antecedent BS. We matched the BS cohort to LT recipients without BS (1:3 matching) based on exact matching for gender and cancer and inverse variance matching for age, LT body mass index, MELD score, and transplant date. RESULTS: We analyzed outcomes in 132 LT recipients (33 BS; 99 non-BS). The BS cohort comprised 26 (79%) women with a mean age of 52.4 years. The BS procedures included 20 Roux-en-Y gastric bypass (61%), 6 jejunoileal bypass (18%), 3 gastric band (9%), 2 sleeve gastrectomy (6%), and 1 duodenal switch (3%). The primary indications for LT listing were alcoholic cirrhosis (9; 27%), nonalcoholic steatohepatitis (7; 21%), hepatitis C (8; 24%), and hepatocellular carcinoma (3; 9%). At LT, body mass index for the BS cohort was 29.6, and MELD was 24. Compared with matched controls, BS recipients did not have longer LT length of hospital stay (17.8 versus 15.7 d, P = 0.71), longer intensive care unit length of stay (5.3 versus 4.1 d, P = 0.16), or higher 30-day complication rate (76% versus 85%, P = 0.43). Overall patient survival was similar (1- and 3-y survival was 90.1% and 75.9% for BS; 90.9% and 76.4% for non-BS, P = 0.34). CONCLUSIONS: A history of BS does not portend a deleterious effect on LT outcomes.
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Cirurgia Bariátrica , Transplante de Fígado , Adulto , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/mortalidade , Bases de Dados Factuais , Feminino , Humanos , Tempo de Internação , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Total pancreatectomy (TP) is a treatment option for patients experiencing chronic pancreatitis (CP) refractory to medical management. Patients who are candidates for TP benefit from islet autotransplantation (IAT), which preserves available ß-cell mass and thereby reduces the risk of brittle diabetes. Malignancy is an absolute contraindication for IAT to prevent the transplantation of occult malignant cells. We present the case of a patient with CP who was approved to undergo TP with IAT (TPIAT) but was intraoperatively discovered to have a pancreatic neuroendocrine tumor. The case illustrates a number of important surgical decision-making considerations for patients undergoing TPIAT and should help guide surgeons should they be presented with this clinical scenario. We stress the importance of vigilance for possible malignancy and to consider an intraoperative biopsy to further investigate unexpected findings that might represent an occult pancreatic malignancy in patients with CP undergoing TPIAT.
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Achados Incidentais , Transplante das Ilhotas Pancreáticas/métodos , Tumores Neuroendócrinos/diagnóstico , Pancreatectomia/métodos , Neoplasias Pancreáticas/diagnóstico , Pancreatite Crônica/cirurgia , Adulto , Tomada de Decisões , Feminino , Humanos , Transplante AutólogoAssuntos
Circuncisão Masculina/economia , Infecções por HIV/prevenção & controle , Medicaid/economia , Doenças do Pênis/prevenção & controle , Pobreza , Circuncisão Masculina/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Humanos , Recém-Nascido , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto , Infecções Sexualmente Transmissíveis/prevenção & controle , Estados UnidosRESUMO
OBJECTIVE: To test the hypothesis that comprehensive efforts to reduce a workforce's health and safety risks can be associated with a company's stock market performance. METHODS: Stock market performance of Corporate Health Achievement Award winners was tracked under four different scenarios using simulation and past market performance. RESULTS: A portfolio of companies recognized as award winning for their approach to the health and safety of their workforce outperformed the market. Evidence seems to support that building cultures of health and safety provides a competitive advantage in the marketplace. This research may have also identified an association between companies that focus on health and safety and companies that manage other aspects of their business equally well. CONCLUSIONS: Companies that build a culture of health by focusing on the well-being and safety of their workforce yield greater value for their investors.