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INTRODUCTION: Popliteal artery aneurysms are in most cases asymptomatic but cause significant complications if ruptured. An acute popliteal aneurysm rupture is relatively rare, and few cases have been documented secondary to blunt trauma. Common presenting signs and symptoms include distal limb ischemia and absent dorsalis pedis pulses. Timely management and recognition of this rare presentation are crucial as this condition can result in limb loss or death if not treated in a timely manner. CASE REPORT: An 80-year-old man with history of hypertension presented to the emergency department complaining of inability to feel sensation below his left knee after falling from ground level. Physical examination was pertinent for bounding radial and femoral pulses bilaterally, although absent dorsalis pedis and posterior tibial pulses to the left lower extremity. Computed tomography angiography identified occlusion of the left superficial femoral arterial lumen associated with a ruptured popliteal aneurysm, approximately eight centimeters in size. He immediately received unfractionated heparin and was admitted to the hospital for left medial thigh exploration and decompressive dermatofasciotomy. CONCLUSION: After confirmation of popliteal aneurysmal rupture with advanced imaging, heparinization and vascular surgery consultation are critical steps that should be taken to prevent limb loss.
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BACKGROUND: Subtotal cholecystectomy is a viable alternative approach to the proverbial "difficult" gallbladder. To date, only a few studies have observed the establishment of those bail-out procedures as an increasingly common surgical practice. The purpose of this study is to assess nationwide trends of subtotal cholecystectomy through evaluation of operative variables and patient- and institution-level characteristics in procedure preference. METHODS: Data were obtained from the National Inpatient Sample for the years between 2003 and 2014. Patients with acute cholecystitis were categorized based on the ninth revision International Classification of Disease Clinical Modification procedure codes for open total, laparoscopic total, open subtotal, or laparoscopic subtotal cholecystectomy. Any patient younger than 18 years of age or with a preoperative stay >1 week was excluded. Logistic regression analysis was performed to evaluate significant patient- and institution-level characteristics associated with the performance of subtotal cholecystectomy. RESULTS: A total of 290,855 patients were evaluated. During the study period, the rate of open and laparoscopic subtotal cholecystectomy sharply increased (0.10% of all cholecystectomy procedures to 0.52% and 0.12% to 0.28%, respectively). The conversion rate from laparoscopic to open total cholecystectomy decreased from 10.5% to 7.6%. Subtotal cholecystectomies were performed at significantly higher rates in men (odds ratio: 1.95, P < .001), Asian Americans (odds ratio: 2.21, P = .037), and patients with alcohol abuse (odds ratio: 2.23, P < .001). Teaching hospitals (odds ratio: 2.41, P < .001) and those in rural areas (odds ratio: 2.26, P < .001) were more likely to perform subtotal cholecystectomies. CONCLUSION: Growing trends in the use of subtotal cholecystectomy suggest evolving surgical practices for acute cholecystitis. Our data suggests that several patient- and hospital-level characteristics might play a deciding role in procedure preference.