Entero-Urachal Fistula: An Unusual Initial Presentation of Penetrating and Stricturing Crohn's Disease.

Crohn's disease (CD) has a wide variety of clinical presentations, ranging from abdominal pain to stricture and fistula. Fistulas involving the genitourinary tract can be severe and often require surgical intervention. Given the array of presenting symptoms, a delay in diagnosis can occur. We present the case of a healthy active duty soldier, with no previous medical history, found to have CD through an initial presentation of isolated umbilical drainage. Imaging workup identified an entero-uracho-cutaneous fistula with involvement of the transverse colon. Urachal anomalies are uncommon, and entero-urachal fistula as an initial presentation of CD is exceedingly rare. This case highlights the need to consider CD in the differential for patients with umbilical drainage despite a lack of concurrent more frequent presenting symptoms (abdominal pain, bloody diarrhea, and perianal fistula). Maintaining awareness of uncommon initial presentations of CD can minimize delay in diagnosis and thereby mitigate the risk of severe complications.

Osteophyte-Sparing Treatment of Mucous Cysts: Case Analysis and Surgical Technique.

OBJECTIVE: The purpose of this study was to examine patient outcomes and the risk of recurrence of mucous cysts affecting the distal interphalangeal (DIP) joint in the absence of osteophytectomy using the described flap technique. METHODS: A retrospective review of 143 records of patients who were treated for mucous cysts of the DIP joint by a single surgeon. Inclusion criteria included the absence of an osteophytectomy during treatment using the described dorsally based flap technique and a minimum of 12 months of follow-up. RESULTS: A total of 143 mucous cysts affecting the DIP joint of 131 patients with an average age of 65.3 years were included. The average follow-up was 21.9 months (12 to 139). Postoperative DIP joint extension was less in the surgical digit compared with the same digit of the contralateral hand with a significant change from the preoperative motion (1.5° versus 0.3°; P = 0.05). No significant change in the postoperative flexion of the DIP joint was observed compared with that of the contralateral side (-1.4° versus -0.9°; P = 0.57). Recurrence occurred in 2 patients (1.4%). No infections or wound complications were identified. CONCLUSIONS: Using the described technique without an osteophytectomy seemed to be an effective treatment of mucous cysts originating from the DIP joint.

The Inverted Free Functioning Gracilis Muscle Transfer For Restoration of Elbow Flexion Following Delayed Presentation or Failed Primary Nerve Reconstruction of Upper Trunk Injuries.

Free functional gracilis transfer is a well-established technique for restoring active elbow flexion in brachial plexus injuries following delayed presentation or failed nerve reconstruction procedures. In cases of delayed presentation or failed nerve reconstruction following upper trunk injuries, the lower trunk intraplexal median and ulnar nerves are spared, thereby making them available to reinnervate the transferred gracilis. Therefore, we have inverted the conventional free functional gracilis orientation so as to orient the flap's recipient nerve in closer proximity to donor median or ulnar nerve fascicles to enable a short, tension-free coaptation in the middle to distal arm. Herein is our descriptive surgical technique for performing an inverted free functional gracilis muscle transfer in order to restore elbow flexion in the setting of an upper trunk injury.

Masseteric-to-Facial Nerve Transfer and Selective Neurectomy for Rehabilitation of the Synkinetic Smile.

IMPORTANCE: Synkinesis is the involuntary movement of 1 area of the face accompanying volitional movement of another; it is commonly encountered in patients affected by facial palsy. Current treatments for synkinesis include biofeedback for muscular retraining and chemodenervation via the injection of botulinum toxin. Chemodenervation is effective in reducing unwanted muscle movement, but it requires a commitment to long-term maintenance injections and may lose effectiveness over time. A permanent solution for synkinesis remains elusive. OBJECTIVE: To evaluate masseteric-to-facial nerve transfer with selective neurectomy in rehabilitation of the synkinetic smile. DESIGN, SETTING, AND PARTICIPANTS: In this case series, 7 patients at a tertiary care teaching hospital underwent masseteric-to-facial nerve transfer with selective neurectomy for synkinesis between September 14, 2015, and April 19, 2018. The medical records of these patients were retrospectively reviewed and demographic characteristics, facial palsy causes, other interventions used, and changes in eFACE scores were identified. INTERVENTION: Masseteric-to-facial nerve transfer. MAIN OUTCOMES AND MEASURES: Changes in eFACE scores (calculated via numeric scoring of many sections of the face, including flaccidity, normal tone, and hypertonicity; higher scores indicate better function and lower scores indicate poorer function) and House-Brackmann Facial Nerve Grading System scores (range, 1-6; a score of 1 indicates normal facial function on the affected side, and a score of 6 indicates absence of any facial function [complete flaccid palsy] on the affected side). RESULTS: Among the 7 patients in the study (6 women and 1 man; median age, 49 years [range, 41-63 years]), there were no postoperative complications; patients were followed up for a mean of 12.8 months after surgery (range, 11.0-24.5 months). Patients experienced a significant improvement in mean (SD) eFACE scores in multiple domains, including smile (preoperative, 65.00 [8.64]; postoperative, 76.43 [7.79]; P = .01), dynamic function (preoperative, 62.57 [15.37]; and postoperative, 75.71 [8.48]; P = .03), synkinesis (preoperative, 52.70 [4.96]; and postoperative, 82.00 [6.93]; P < .001), midface and smile function (preoperative, 60.71 [13.52]; and postoperative, 78.86 [14.70]; P = .02), and lower face and neck function (preoperative, 51.14 [16.39]; and postoperative, 66.43 [20.82]; P = .046). Preoperative House-Brackmann Facial Nerve Grading System scores ranged from 3 to 4, and postoperative scores ranged from 2 to 3; this change was not significant. CONCLUSION AND RELEVANCE: This study describes the application of masseteric-to-facial nerve transfer with selective neurectomy for smile rehabilitation in patients with synkinesis, with statistically significant improvement in smile symmetry and lower facial synkinesis as measured with the eFACE tool. This technique may allow for long-term improvement of synkinesis and smile. This study is only preliminary, and a larger cohort will permit more accurate assessment of this therapeutic modality. LEVEL OF EVIDENCE: 4.

Military Medicine and the Academic Surgery Gender Gap.

INTRODUCTION: Gender disparity in academic medicine has been well described in the civilian sector. This has not yet been evaluated in the military health system where hundreds of female surgeons are practicing. Military service limits factors such as part time work and control over time spent away from family, which are often cited as contributors to the pay and promotion gap in civilian academic medicine. The military has explicit policies to limit discrimination based on gender. Pay between men and women is equal as it is based on rank and time in rank. One would expect to see less disparity in promotion through the academic ranks for military female surgeons given this otherwise equal treatment. This has not previously been objectively tracked or reported. It is beneficial to characterize the military academic medicine gender gap and benchmark against national data to define the academic gender gap and lay the groundwork for future work to identify factors contributing to the observed difference. MATERIAL AND METHODS: This study was granted exemption from the Walter Reed National Military Medical Center (WRNMMC) Internal Review Board (IRB). The Uniformed Services University (USU) Department of Surgery academic appointment list was reviewed to assess female representation in the categories of Instructor, Assistant Professor, Associate Professor, Professor, and Other. Defense Manpower Data Center (DMDC) and the US Navy Bureau of Medicine and Surgery (BUMED) were assessed for total numbers of female surgeons on active duty, and numbers were compared with nationally published Association of American Medical Colleges (AAMC) data using a logistic regression model. RESULTS: There was a higher proportion of women in academic positions in the civilian cohort than in the military cohort (OR: 1.84; CI: 1.53-2.21, p < .0001). This difference was observed at every level of academic achievement. A higher percentage of women were observed at lower levels of professorship than at higher levels; instructors were more likely to be women than assistant professor (OR: 1.44, CI:1.16-1.79), associate professor (OR: 2.24, CI: 1.77-2.84), or full professor (OR:4.61, CI: 3.57-5.94). CONCLUSIONS: Fewer female surgeons in military medicine hold academic appointment when compared with their counterparts in civilian medicine. Similar to the civilian sector, military academic surgery also demonstrates less likelihood of female representation in higher academic stations. This discrepancy in representation follows a linear trend over the different ranks. This discrepancy has not been previously documented. The military offers a unique opportunity to study the issue of gender imbalance in academic promotion practices given its otherwise equal treatment of males and females. Additional studies will be necessary to understand uniformed female surgeons' barriers to academic advancement.

Metachronous Contralateral Male Breast Cancer: Case Report and Literature Review.

Male breast cancer (MBC) is rare and consequently understudied. Here we present the case of contralateral breast cancer in a male patient nearly a quarter century following his initial breast cancer diagnosis and treatment. The epidemiology, risk factors, diagnosis, characterization, treatment, and prognosis of male breast cancer are reviewed. MBC accounts for <1% of all breast cancer with an estimated incidence nearly 1.25 per 100,000 person years. Our patient tested positive for ATM mutation of undetermined significance. More commonly in males, a BRCA2 mutation confers a >1 in 15 lifetime risk of breast cancer and is present in >11% of MBC patients, while BRCA1 is present in an estimated <1.5% of MBC patients. The risk of contralateral breast cancer developing in a male with a unilateral lesion is much higher than for a primary male breast cancer in the general population. Men tend to be diagnosed at a later age and stage than females. Prognosis for male and female breast cancer is similar considering both age of patient and stage of the tumor at diagnosis, and similar treatment paradigms have resulted in similar outcomes. Although lumpectomy with radiation therapy may have the same prognosis as mastectomy, the standard of care for male breast cancer continues to be simple mastectomy with sentinel lymph node biopsy.

A Surgeon's Guide to Obtaining Hemorrhage Control in Combat-Related Dismounted Lower Extremity Blast Injuries.

The application of lessons learned on the battlefield for timely surgical control of lower extremity hemorrhage secondary to blast injuries to the civilian practice for similar wounding patterns from industrial accidents or terrorist activities is imperative. Although simple cut-down procedures are commonly sufficient for the control of blood vessels for distal extremity traumatic amputations, high-thigh or disarticulation wounding patterns often require more complex surgical methods. The following details both the decision-making process and operative techniques for controlling hemorrhage from lower extremity blast injuries.

A staged repair of crossed fused renal ectopia with complex abdominal aortic and iliac aneurysms.

Crossed fused renal ectopia in the presence of abdominal aortic aneurysms (AAAs) is a rare challenge to therapy. A 68-year-old man had a 6.9-cm AAA, a 6.6-cm left common iliac aneurysm, and a 3.2-cm right internal iliac aneurysm. He had multiple comorbidities and a right-sided crossed fused kidney supplied by two small renal arteries arising from the AAA. Aortorenal bypass with staged endovascular aneurysm repair was used to treat the aneurysmal disease. Two-stage open aortorenal bypass followed by endovascular repair for complex aneurysms is feasible in the rare patient with such a congenital anomaly.

Traumatic ulnar artery pseudoaneurysm following a grenade blast: report of a case.

Vascular injuries comprised a small percentage of total injuries requiring medevac in the Iraq and Afghanistan conflicts; however, their impact cannot be overstated. This case highlights an individual who sustained a grenade blast injury leading to hemorrhage, and forearm compartment syndrome. He was initially treated with irrigation and debridement, forearm fasciotomy, and delayed primary closure. The patient developed persistent ulnar neuropathy and hypothenar atrophy despite a normal initial vascular examination. During reconstructive surgery, he was discovered to have a proximal ulnar artery pseudoaneurysm. Upper extremity pseudoaneurysms are a rare sequelae following vascular injury, but have significant consequences for the patient and are identifiable by imaging.

Emergent management of postpartum hemorrhage for the general and acute care surgeon.

BACKGROUND: Postpartum hemorrhage is one of the rare occasions when a general or acute care surgeon may be emergently called to labor and delivery, a situation in which time is limited and the stakes high. Unfortunately, there is generally a paucity of exposure and information available to surgeons regarding this topic: obstetric training is rarely found in contemporary surgical residency curricula and is omitted nearly completely from general and acute care surgery literature and continuing medical education. METHODS: The purpose of this manuscript is to serve as a topic specific review for surgeons and to present a surgeon oriented management algorithm. Medline and Ovid databases were utilized in a comprehensive literature review regarding the management of postpartum hemorrhage and a management algorithm for surgeons developed based upon a collaborative panel of general, acute care, trauma and obstetrical surgeons' review of the literature and expert opinion. RESULTS: A stepwise approach for surgeons of the medical and surgical interventions utilized to manage and treat postpartum hemorrhage is presented and organized into a basic algorithm. CONCLUSION: The manuscript should promote and facilitate a more educated, systematic and effective surgeon response and participation in the management of postpartum hemorrhage.