Intra-abdominal Cystic Lymphangiomas: The Vanderbilt Experience.

INTRODUCTION: Lymphangiomas are rare, cystic tumors that represent congenital malformation of the lymphatic vessels. We reviewed our institution's experience treating abdominal lymphangiomas with the purpose of describing the clinical features, management, and outcomes of this rare pathology. METHODS: This is a single-institution, institutional review board-approved retrospective review of abdominal lymphangiomas presenting between January 2010 and February 2021. The diagnosis of lymphangioma was made on histopathology from either endoscopic or excisional biopsy of the lesion. Demographics, diagnostic imaging, histopathologic characteristics, and outcomes were analyzed. RESULTS: We identified 48 patients, of whom 29 (60%) were female, >18 y (38; 79%), with a mean age of 43 y at the time of diagnosis (range, 4 d-87 y). Tumors ranged in size from <1 cm to 30 cm. Only 1/3 were symptomatic, most commonly with abdominal pain (9; 19%) On preoperative imaging, mural nodules or thickened walls were present in one case, in which pathology was consistent with benign lymphangioma. The majority of lymphangiomas were associated with the small bowel or its mesentery (31; 65%), followed by the colon/omentum (7; 15%). Most patients underwent surgical excision (29; 60%) with incomplete excision in one patient due to extensive local invasion, and three (10%) patients required multivisceral resection. The median duration of the follow-up was 13 mo (range, 1-105 mo), during which time, none of the patients developed malignancy. CONCLUSIONS: Most abdominal lymphangiomas arise from the small bowel and are found incidentally and have a favorable prognosis. Resection should be reserved for symptomatic lesions or when there is a diagnostic uncertainty.

Postoperative and Recurrent Hematuria after Pretransplant Core Needle Biopsy in Living Donor Kidney Transplant.

Background: Core needle and wedge biopsies are the two main pathologic ways to determine the suitability of a kidney allograft and to have a baseline allograft biopsy in case of future rejection. Case Presentation. A 57-year-old patient developed a renal arteriovenous fistula causing postoperative and recurrent hematuria after allograft pretransplant renal core needle biopsy and treated with selective Interventional radiology coil embolization. Conclusion: Delayed profound hematuria can be seen after pretransplant core needle renal biopsies and can recur again even after complete resolution, due to arteriovenous fistula formation in the renal calyceal system.

Orthotopic Kidney Transplant as a Fifth Intra-Abdominal Organ after Two Previous Kidney and Two Previous Pancreas Transplants.

Background: Patients with more than two prior kidney transplant procedures pose unique surgical challenges. Once both the right and left retroperitoneal spaces have been dissected, intra-abdominal implantation is usually necessary. If the external iliac arteries have been used previously, it is sometimes necessary to use the aorta and vena cava for implantation. Gaining safe exposure in these cases can be complicated by history of prior laparotomy, adhesive disease, and other surgical histories. Case Presentation. A 58-year-old female with type 1 diabetes and end-stage renal disease presented for surgical evaluation for kidney transplant. Surgical history was notable for prior simultaneous kidney-pancreas transplant followed by both a living donor kidney transplant and a pancreas after kidney transplant. She had undergone both an allograft nephrectomy and an allograft pancreatectomy and currently had a nonfunctioning kidney in the left retroperitoneal position and a nonfunctioning pancreatic allograft on the right common iliac artery. The entire distal aortoiliac system was surgically inaccessible. She was listed for transplantation, and a cadaveric graft was allocated. Intraoperatively, severe lower abdominal and pelvic adhesions prevented any use of the iliac system. A left native nephrectomy was performed, and the allograft was implanted in the left orthotopic position. The native left renal vein was used for outflow, the donor renal artery was joined end-to-side to the infrarenal aorta, and a uretero-ureterostomy was created. The operation was uneventful. The allograft functioned without delay, and almost one year later, the GFR is approximately 50 mg/dL. Conclusion: The left orthotopic position can be a good choice for kidney transplant candidates with histories of prior complex lower abdominal surgery.

Spinal Stroke following Kidney Transplant.

Complications are a part of surgery. Spinal infarctions are a dreaded complication of aortic surgery. We present a patient who developed a spinal infarct after a kidney transplant. We were unable to find a causative factor in our search for etiology. In our review of the literature, we were unable to find a similar report. We present this case report to highlight a rare complication of kidney transplantation and to reinforce that patients requiring kidney transplant are complex patients with multiple comorbidities that can cause a multitude of complications in the periop period.

The choices we make: Ethical challenges in trauma surgery.

BACKGROUND: Ethical issues in trauma surgery are commonplace but scarcely studied. We aim to characterize the ethical dilemmas trauma surgeons encounter in clinical practice and describe perceptions about the ability to manage these dilemmas and strategies they use to address them. METHODS: Members of a U.S. trauma society were electronically surveyed on handling ethically challenging scenarios. The survey instrument was developed using published ethics literature and iterative cognitive interviews. Domains included perceived frequency of encountering and self-efficacy of managing ethical situations in trauma surgery. Common situations were defined as those encountered monthly or weekly. Ethical problems were categorized within 7 larger categories: general ethics, autonomy, communication, justice, end-of-life, conflict, and other. Descriptive analyses were performed; group comparisons were analyzed using analysis of variance. RESULTS: Of 1,748 surveyed, 548 responded (30.6%) and 154 (28%) were female. Most were White, under 55 years age, had completed fellowship training, and were practicing at a level I or II trauma center. The most encountered ethical categories were generic ethics and communication (79%). Issues involving conflict were least frequent (21%). Respondents felt most uncomfortable with autonomy topics. Respondents with high self-efficacy in handling ethical situations were older, in practice ≥15 years, served on an ethics committee, and/or frequently experienced ethical challenges. CONCLUSION: Most trauma surgeons regularly encounter ethical challenges, especially those related to communication. Trauma surgeons encounter ethical issues involving conflict least often, and lowest self-efficacy scores with issues involving autonomy. Experienced trauma surgeons reported higher self-efficacy scores in managing ethical issues. Future work should examine how self-efficacy translates to observed behavior, and how trauma surgeons build and enhance their ethical skillsets in the care of the injured patient.

Determining the impact of body mass index on ultrasound accuracy for diagnosing appendicitis: Is it less useful in obese children?

BACKGROUND: Ultrasonography (US) is the preferred imaging for suspected pediatric appendicitis. We hypothesize that children with elevated Body-Mass-Index-for-age percentile (BMIP) may be more likely to have an inaccurate or equivocal (IE) US. METHODS: After IRB approval, a four-year review was performed on pediatric patients evaluated for appendicitis by US. The CDC BMIP Calculator was used. IE subgroups were analyzed together for comparison against the accurate group. RESULTS: 1059 patients were included: median age 11.3 years (IQR: 8.2, 14.6), 506 (47.8%) males. Median BMIP was 65.9 (IQR: 33.9, 89.6). US accurately diagnosed 857 (80.9%), incorrectly diagnosed 76 (7.2%), 126 (11.9%) were equivocal. Overall sensitivity was 0.85, specificity 0.96, PPV 0.93 and NPV 0.91. Obese children (BMIP ≥95%), had higher odds of IE US (OR: 1.86, 95% CI: 1.28, 2.70; p = 0.001). When analyzed by sex, risk increased in obese males (OR: 2.55, 95% CI:1.53, 4.24; p = 0.0003) but normalized in obese females (OR: 1.30, 95% CI:0.74, 2.28; p = 0.35). CONCLUSIONS: An elevated BMIP may increase difficulty in visualizing the appendix, resulting in inaccurate or equivocal findings. This risk is seen specifically in obese males. If US findings do not correlate with clinical assessment in obese children with abdominal pain, further evaluation may be warranted.

Neonatal Perforated Appendicitis Attributed to Localized Necrotizing Enterocolitis of the Appendix: A Review.

Neonatal appendicitis is a rare clinical entity associated with remarkable morbidity and mortality. Appendicular perforation is common and the diagnosis is usually made intra-operatively. The causative etiology of neonatal perforated appendicitis (NPA) is a subject of debate and has not been elucidated. Although many etiologic theories exist, increasing evidence suggests a subset of NPA cases may represent a form of necrotizing enterocolitis (NEC) localized to the appendix. We herein present a review of the current literature to include cases of NPA attributed to localized NEC. A high index of clinical suspicion and early laparotomy are recommended.

Neonatal Perforated Appendicitis Masquerading as Necrotizing Enterocolitis.

A preterm neonate underwent emergent laparotomy for presumed necrotizing enterocolitis (NEC). Intra-operatively, neonatal perforated appendicitis (NPA) was encountered. This may represent a form of NEC localized to the appendix. A high index of clinical suspicion and early laparotomy are recommended.

Surgical informed consent in children: a systematic review.

BACKGROUND: The purpose of the article was to analyze current literature on surgeon and parents' understanding and role in the informed consent process for children undergoing surgery. METHODS: A systematic database search (MEDLINE, EMBASE, PsycINFO, and EBM Reviews) was performed to identify articles concerning any aspect of the surgical informed consent for children undergoing an invasive procedure. Articles analyzing informed consent in research studies, non-English-language articles, review articles, case reports and/or series, letters-commentaries, and dentistry and/or nursing-related articles were excluded. Articles meeting inclusion criteria were analyzed to identify common themes related to the process of informed consent. RESULTS: One hundred seventy-eight articles were identified on primary search, after removing duplicates and screening titles for relevance, 83 abstracts were reviewed. Thirty-two additional abstracts were identified by secondary search. Twelve of 115 articles met inclusion criteria. Analysis identified five different study themes. Information delivered during consent (Content) was studied in five articles (42%), three (25%) studied the mechanics or delivery of the information (Delivery), three (25%) studied parent participation and discussion (Interchange), six articles (50%) discussed surgeons' perceptions or the parents' ability to understand or recall the information (Comprehension), and five articles (42%) evaluated surgeon or parent satisfaction or anxiety (Satisfaction). None of the articles studied all five categories. CONCLUSIONS: Studies of the surgical informed consent process in children are scarce. Prospective studies evaluating surgeon and parent perception regarding the Content, Delivery, and Interchange of information as well as Comprehension and Satisfaction are needed to understand barriers to the surgeon-patient relationship and to optimize the informed consent process in children undergoing surgery.

Pediatric near-drowning events: do they warrant trauma team activation?

BACKGROUND: The purpose of this study was to determine the incidence of traumatic injuries, factors associated with mortality, and need for pediatric trauma surgery involvement for drowning and near-drowning events in children. MATERIALS AND METHODS: An institutional review board-approved, retrospective chart review was performed at three American College of Surgeons-verified Pediatric Trauma Centers (2011-2014). Patients with International Classification of Diseases, Ninth Revision, codes or E-codes for fatal-nonfatal drowning, fall into water, accidental drowning, or submersion were included. Bivariate analysis using chi-square or Fisher exact test for nominal variables and Mann-Whitney U test for continuous variables was performed. RESULTS: A total of 363 patients (median 3.17 y [18 d-17 y]) met the inclusion criteria. Drowning sites included pool (81.5%), bathtub (12.9%), and natural water (5.2%). A witnessed fall or dive was reported in 34.9%, 57.9% did not fall or dive, and 7% had an unwitnessed event. Most patients did not undergo cervical spine (83%) or brain imaging (75.5%). Seven patients (1.92%) had associated soft tissue injuries. Two patients (0.006%) received surgical intervention (bronchoscopy and extracorporeal membrane oxygenation) within 24 h of presentation. Only 2.2% were admitted to the pediatric trauma service. The percentage of patients discharged home from the emergency department was 10.2%. Overall mortality was 12.4%. Factors associated with mortality included transfer from outside hospital (P = 0.016), presence of hypothermia on arrival (P < 0.0001), Glasgow Coma Scale of 3 on arrival (P < 0.0001), drowning in a pool (P = 0.013), or undergoing brain cooling at admission (P = 0.011). CONCLUSIONS: This is the largest reported series of pediatric near-drowning events. Only rarely did patients require immediate surgical attention and the majority were admitted to nonsurgical services. These data suggest that routine pediatric trauma surgery service involvement in patients with near-drowning events may be unnecessary.

Post-resection outcomes for pediatric ovarian neoplasm: is ovarian-preserving surgery a good option?

PURPOSE: Pediatric surgeons often care for children with ovarian tumors. Few studies report long-term outcomes for these patients. This study characterizes intermediate-term results for patients who underwent surgical resection of ovarian neoplasms as children. METHODS: Patients who underwent surgery for ovarian neoplasms at a children's hospital were identified. They were invited to participate in a telephone-based survey assessing post-surgical recurrence, dysmenorrhea, quality of life, and fertility. RESULTS: 188 patients were identified; 79 met criteria. 31 patients had ovarian-sparing tumor resection; 48 had oophorectomy; five had recurrences. 56 were successfully interviewed at a median follow-up of 4.6 years. Dysmenorrhea rates of 52 and 78 % were reported (p = 0.07), respectively. Two patients suffered from infertility. Quality of life was generally reported as good. CONCLUSION: Intermediate outcomes are good for patients who underwent ovarian-sparing tumor resection or oophorectomy for pediatric ovarian tumors. Additional long-term monitoring would be beneficial to better assess fertility and dysmenorrhea outcomes.

Recurrent Arterial Thrombosis as a Presenting Feature of a Variant M3-Acute Promyelocytic Leukemia.

Acute limb ischemia (ALI) is a common vascular emergency. Hematologic malignancies are commonly associated with derangement of normal hemostasis and thrombo-hemorrhagic symptoms during the course of the disease are common. However, ALI as an initial presenting feature of acute leukemia is rare. Due to the rarity of this presentation, there is a scarcity of prospective randomized data to optimally guide the management of these patients. Current knowledge is mainly based on isolated cases. We report our experience managing a patient who presented with ALI and was found to have occult leukemia. A review of all cases with ALI as a presenting feature of acute leukemia is also presented.

Outcomes of trochanteric external fixation for geriatric inter-trochanteric hip fractures.

INTRODUCTION: Trochanteric fractures are a leading cause of disability among the elderly. Internal fixation is the gold standard treatment. However, it may be challenging in the high-risk population. We present our results using external fixator in trochanteric fractures in the elderly. PATIENTS AND METHODS: During 2005-2012, twenty-three high-risk elderly patients (average age 70 years) with trochanteric fracture were managed using percutaneous external fixation (EF). RESULTS: At one year follow-up, 86% returned to pre-fracture ambulatory status. Average time to fixator removal was 14 weeks. There were no cases of pin loosening, breakage, or penetration of femoral head. CONCLUSION: Advantages of EF include avoidance of delay, use of local/regional anesthesia, and shorter duration of surgery, blood loss and hospital stay. EF is an acceptable alternative in this patient population, given the associated co-morbidities and especially due to limited resources in developing countries.

Posterior sternoclavicular dislocation presenting with upper-extremity deep vein thrombosis.

Posterior sternoclavicular dislocation is an uncommon injury and often remains initially undiagnosed due to variable clinical presentation and inadequate visualization of the joint on plain radiographs. It is frequently associated with serious and life-threatening injuries involving the trachea, esophagus, or great vessels. A 15-year-old boy was knocked to the ground during wrestling and landed on his left shoulder. He presented 6 days after trauma with increasing arm swelling and pain. A Doppler ultrasound revealed deep vein thrombosis involving the left shoulder and arm. Contrast-enhanced computed tomography of the chest confirmed the diagnosis of left posterior sternoclavicular dislocation with the medial end of left clavicle compressing the underlying brachiocephalic vein. Venous duplex scan confirmed acute venous thrombosis of the left jugular and subclavian veins. Open reduction of the left posterior sternoclavicular dislocation was performed under general anesthesia with cardiothoracic surgery backup. The reduced joint was stable, negating the need for internal fixation. Postoperatively, the pain and arm swelling gradually subsided, and patient recovered well with no complications. Deep vein thrombosis has not been reported as a presenting symptom for posterior sternoclavicular dislocation. Orthopedic, trauma, and thoracic surgeons should be aware of this presentation and obtain a chest computed tomography scan with 3-dimensional reconstruction to confirm the diagnosis. In cases of posterior sternoclavicular dislocation with vascular compromise, patients should immediately undergo open reduction with or without internal fixation.