Supercharged deep inferior epigastric perforator flap for reconstruction of soft tissue defect after excision of giant invasive squamous cell carcinoma of the thigh in a refractory diabetic with Pseudomonas aeruginosa infection.

Patients with large defects after oncologic surgery often require enhanced surgical planning to optimize reconstructive outcomes. As such, medically complex patients require innovative solutions when utilizing abdominal flaps due to concern for ischemia of the distal tissue. Vascular augmentations, such as supercharging or turbocharging, serve to increase perfusion in these medical complex patients to ensure flap survival. In this report, we highlight the use of a supercharged bilateral pedicled deep inferior epigastric perforator (DIEP) flap in a patient with a 231 cm2 thigh defect in the setting of uncontrolled diabetes. A 57-year-old male with poorly-controlled diabetes (blood sugar prior to surgery 510 mg/dL) and iron deficiency anemia presented with a two-year history of a large nonmetastatic squamous cell carcinoma (SCC) measuring 19 × 9 cm2 on the right thigh. Positron emission tomography/computed tomography and biopsies of the right retroperitoneal and inguinal lymph nodes diagnosed the mass as Stage 3 localized SCC. After excision, we performed immediate reconstruction of the resultant defect with a supercharged bilateral pedicled DIEP flap. The flap was pedicled on the ipsilateral DIEP and the contralateral perforator was anastomosed to the descending branch of the lateral circumflex femoral artery (DLCFA) at the inferior aspect of the defect. A venous coupler was used for the veins and the arteries were hand-sewn in end-to-end fashion. The supercharged bilateral pedicled DIEP flap was utilized for enhanced augmented perfusion to the distal edge of the pedicled flap in a high-risk patient. The patient's clinical course was complicated by a Pseudomonas infection of a small hematoma requiring operative washout and debridement of necrotic fat. However, the flap survived and covered the defect completely. The patient required outpatient antibiotics for the Pseudomonas infection which resolved completely without further need for operative intervention. At 6-month follow up, the reconstruction was stable with no tumor recurrence on clinical exam. Our results suggest that a supercharged pedicled DIEP flap may be a viable option for large defects of the thigh and can may be utilized in medically complex patients with poor capacity for wound healing.

Regional abdominal wall nerve block versus epidural anesthesia after hepatectomy: analysis of the ACS NSQIP database.

BACKGROUND: The aim of this study is to determine whether regional abdominal wall nerve block is a superior to epidural anesthesia (EA) after hepatectomy. METHODS: Patients undergoing open hepatectomy in the NSQIP targeted file (2014-2016) were identified. Those with INR > 1.5, Platelets < 100, bleeding disorders, undergoing liver ablation without resection, and spinal anesthesia were excluded. Patients with regional abdominal wall nerve block (RAB), mostly transversus abdominis plane (TAP) block, were matched (1:1) to those undergoing EA using propensity scores to adjust for baseline differences. RESULTS: Out of 1727 patients who met our inclusion criteria, 361 (21%) had RAB. Of whom 345 were matched (1:1) to those who underwent EA. The matched cohort was well-balanced regarding preoperative characteristics, extent of hepatectomy, concurrent ablations as well as biliary reconstruction. RAB was associated with shorter hospital stay (median: 6 days vs. 5 days, p = 0.007). Overall morbidity (44.1% vs. 39.4%, p = 0.217), serious morbidity (27% vs. 25.2%, p = 0.603), and mortality (2.6% vs. 2.3%, p = 0.806) were not different between the two groups. Individual complications, readmission rate, and blood transfusion were not different between the two groups. CONCLUSION: Regional abdominal nerve block is associated with shorter hospital stay than epidural anesthesia without an increase in overall postoperative morbidity or mortality. RAB is a viable alternative anesthesia adjunct to EA in patients undergoing hepatectomy. However, given the retrospective nature of this study further studies comparing the modalities should be considered to definitively define the utility of RAB.

Comorbidity and outcomes after surgery among women with breast cancer: analysis of nationwide in-patient sample database.

To examine the effect of comorbidity on risk of postoperative complications, prolonged hospitalization (defined as above median length of stay), non-routine disposition, and in-patient death among women with breast cancer after surgery. Nationwide in-patient sample is a nationwide clinical and administrative database. Discharges of patients aged 40 years and older who underwent surgery for breast cancer from 2005 to 2009 were identified. Information about patients and hospitals characteristics were obtained. Comorbidities were identified and used to calculate Charlson comorbidity index (CCI) score. We divided patients based on these scores into four groups: 0, 1, 2, and ≥3. Multivariate logistic regression analyses were used to examine risk adjusted association between CCI score and the aforementioned outcomes. We identified 70,536 patients' discharges. Compared to a CCI score of zero as a reference group, CCI scores of 1, 2, and ≥3 increased the risk of post-operative complications by 1.7-fold, 2.6-fold, and 4.6-fold, respectively (p < 0.001). Patients with CCI scores of 1, 2, and ≥3 had higher risk of non-routine disposition by 1.3-folds, 1.7-folds, and 2.2-folds, respectively (p < 0.001). Patients with CCI scores of 1, 2, and ≥3 had higher risk of prolonged hospitalization by 1.2-folds, 1.6-folds, and 2.3-folds, respectively (p < 0.001). Similarly, CCI scores of 1, 2, and ≥3 increased risk of in-patient death by 3.1-folds (p 0.05), 5.4-folds (p 0.008), and 15.8-folds (p < 0.001), respectively. Comorbidity associated with worse in-hospital outcomes among women with breast cancer after surgery. Effective control of comorbidity in breast cancer patients may reduce post-operative morbidity and mortality.

Racial disparities in clinical presentation, surgical treatment and in-hospital outcomes of women with breast cancer: analysis of nationwide inpatient sample database.

To examine racial/ethnic disparities in stage of disease and comorbidity (pre-treatment), surgical treatment allocation (breast-conserving surgery versus mastectomy), and in-hospital outcomes after surgery (post-treatment) among women with breast cancer. Nationwide inpatient sample is a nationwide clinical and administrative database compiled from 44 states representing 95 % of all hospital discharges in the Unites States. Discharges of adult women who underwent surgery for breast cancer from 2005 to 2009 were identified. Information about patients and hospitals characteristics was obtained. Multivariate logistic regression analyses were used to examine the risk adjusted association between race/ethnicity and the aforementioned outcomes (pre-treatment, treatment, and post-treatment). We identified 75,100 patient discharges. Compared to Whites, African-Americans (1.17, p < 0.001), and Hispanics (1.20, p < 0.001) were more likely to present with regional or metastatic disease. Similarly, African-American (1.58, p < 0.001) and Hispanics (1.11, p 0.003) were more likely to have comorbidity. Compared to Whites, African-Americans (0.71, p < 0.001), and Hispanics (0.77, p < 0.001) were less likely to receive mastectomy. Compared to Whites, African-Americans were more likely to develop post-operative complications (1.35, p < 0.001) and in-hospital mortality (1.87, p 0.13). Other racial groups showed no statistically significant difference compared to Whites. After controlling for potential confounders, we found racial/ethnic disparities in stage, comorbidity, surgical treatment allocation, and in-hospital outcomes among women with breast cancer. Future researches should examine the underlying factors of these disparities.

Laparoscopic excision of splenic artery aneurysm.

INTRODUCTION: Splenic artery aneurysm is more frequently diagnosed today with the advancement and liberal use of imaging modalities. A symptomatic aneurysm, an aneurysm of any diameter in a pregnant woman or a woman of childbearing age, and an aneurysm >2 cm are all strong indications for surgery because of a significantly increased risk for splenic artery rupture. CASE DESCRIPTION: A 35-year-old, morbidly obese, African American woman presented with constant left flank pain for 4 weeks. Angiography confirmed a 2.5-cm splenic artery aneurysm near the splenic hilum. Because angioembolization was unlikely to succeed because of extensive collaterals and the aneurysm's proximity to the splenic hilum, laparoscopic excision of the aneurysm with splenectomy was performed. DISCUSSION: We report the successful laparoscopic surgical treatment of a 2.5-cm splenic artery aneurysm. Any splenic artery aneurysm with a significantly increased risk of rupture requires a prompt intervention. Although percutaneous embolization of the splenic artery is the most frequently applied therapy today, surgical repair is preferred for all symptomatic aneurysms because of the greater likelihood of success.

The Role of the Urinary Bladder in the Diagnosis of Abdominal Compartment Syndrome: A Prospective Study in Trauma Patients.

Purpose The aim of this study was to evaluate the accuracy of bladder pressures in the diagnosis and management of abdominal compartment syndrome (ACS). Methods After Institutional Review Board (IRB) approval, nine operative abdominal trauma patients were prospectively studied over an 18-month period. Bladder pressures were compared to pressures obtained from intra-operatively placed electronic transducer located in the pelvis. Statistical analysis was performed using methods described by Bland and Altman. Results A Bland-Altman plot was used to assess the differences between bladder and transducer pressures. There was little agreement between the two methods at low (10-15 mmHg) and high (30-70 mmHg) pressures. At higher pressures, there was a notable difference between these two types of pressure. No patients required repeated operation. One patient died from severe traumatic brain injury. Conclusion Measurements obtained from the urinary bladder did not agree well with those obtained from within the peritoneal cavity. Furthermore, abdominal pressures greater than 20 mmHg did not show signs of ACS in this selected population, raising doubts about the utility of using abdominal pressures alone in the management of ACS.

Laparoscopic excision of a preperitoneal incidentaloma.

BACKGROUND: Dermoid cysts are rare well-differentiated benign tumors derived from ectodermal cell origins. Usually caught incidentally, they have the potential for mass effect, malignant degeneration, and rupture. Dermoid cysts can often present a unique surgical challenge. CASE REPORT: A 69-year-old male brought to the emergency department after a motor-vehicle accident had a preperitoneal incidental mass discovered on imaging. The patient was asymptomatic from the mass, though it was expanding in size. He was advised to have the mass removed, because of the possibility of malignant degeneration and rupture, and he was taken for laparoscopic surgical excision of the mass. DISCUSSION: Dermoid cysts develop from embryonic migration of ectodermal tissue to aberrant locations or implantation of epidermal tissue. Dermoid cysts in the abdominal cavity are rare, and only case reports exist characterizing these tumors. Rupture can result in a chemical granuloma when localized and can cause peritonitis when the rupture is throughout the entire abdomen. Rare reports of malignant degeneration are also reported in the literature. Surgical excision is the standard of care minimizing risk of rupture with removal.

Mid-Year Medical Knowledge Milestones and ABSITE Scores in First-Year Surgery Residents.

OBJECTIVE: Accreditation Council for Graduate Medical Education (ACGME) Surgery milestone ratings in the "Knowledge of Diseases and Conditions" (MK1) sub competency have been shown to correlate with American Board of Surgery In Training Examination (ABSITE) scores, and hypothesized to predict them. To better assess the predictive value of the MK1 milestone and avoid the potential bias caused by previous years' ABSITE scores, we designed a study including only first-year (PGY-1) residents and analyzed the correlation between their mid-year MK1 ratings and their scores in the ABSITE they took approximately a month later. METHODS: De-identified United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, mid-year MK1 milestone ratings and the subsequent ABSITE standard scores for the five academic years from 2014-2015 to 2018-2019 were collected and tabulated for 247 PGY-1 preliminary- and categorical-track residents from ten ACGME-accredited surgery residency programs. RESULTS: The mid-year rating of PGY-1 residents' MK1 was predictive of their subsequent first ABSITE score for the entire cohort and for the categorical residents' subset. Notably, controlling for all other independent predictors, each half-point increase in MK1 rating was associated with a 25-point increase in ABSITE score. Preliminary residents performed significantly worse on the ABSITE, and their scores did not correlate significantly with their MK1 ratings. CONCLUSIONS: The mid-year rating of PGY-1 residents' MK1 was predictive of their subsequent first ABSITE score for the entire cohort and for the categorical but not the preliminary residents. This finding suggests that evaluators correctly rated MK1 higher in the categorical residents who did perform better on the subsequent ABSITE.

Horse Kick to the Abdomen Causing a Triad of Injury: A Case Report.

A 35-year-old male, a horse trainer, was brought to the emergency room after being kicked in the abdomen, which resulted in an abdominal wall hematoma and a blow-out rupture of the proximal jejunum, with a mesenteric tear and posterior lumbar disc herniation. The initial evaluation did not raise significant concerns; however, the patient's abdominal pain progressively worsened after the administration of oral contrast in preparation for the computed tomography (CT) scan. The patient did well after abdominal exploration and operative repair of the small bowel injury. Our objective is to shed light on this mechanism of injury that can be underestimated during a patient's initial evaluation.

Inferior Vena Cava Calcified Thrombus Presenting With Abdominal Pain: A Case Report.

De novo thrombosis of the inferior vena cava (IVC) can cause significant morbidity and mortality. Calcified thrombus of IVC is an extremely rare incidental finding and is associated with recurrent deep venous thrombosis (DVT) and pulmonary embolism (PE). We present a case of abdominal pain secondary to a calcified thrombus in the supra-hepatic region of the IVC.

Small Bowel Intussusception Caused by Metastatic Melanoma: A Case Report.

Intussusception, as a rare cause of small bowel obstruction, can be secondary to benign or malignant pathology. Malignant lesions causing intussusception can be primary or metastatic lesions. Metastasis can occur many years later. We present a case of metastatic melanoma in a 69-year-old man as the underlying etiology of his intussusception. The patient had laparoscopic Roux-en-Y gastric bypass four years prior to his presentation and did recall excision of a skin melanoma at age 64. Laparoscopic or open surgical resection is the best therapeutic option in cases such as this.

Feeding Jejunostomy Tube Placed during Esophagectomy: Is There an Effect on Postoperative Outcomes?

BACKGROUND: Feeding jejunostomy (FJ) tubes are routinely placed during esophagectomy. However, their effect on immediate postoperative outcomes in this patient population is not clear. OBJECTIVES: To evaluate the effect of FJ tube placement during esophagectomy on postoperative morbidity and mortality. METHODS: The National Surgical Quality Improvement Program database was used to evaluate the effect of FJ tube placement during esophagectomy on 30-day postoperative morbidity and mortality rates. A propensity score-matched cohort was used to compare postoperative outcomes of patients with and without FJ tubes. RESULTS: An FJ tube was placed in 45% of 2059 patients undergoing esophagectomy. The anastomotic leak rate was 13.5%. Patients with FJ tubes were more likely to have preoperative radiation therapy (59.6% vs 54.9%, p = 0.041), transhiatal esophagectomy (21.5% vs 19.2%, p = 0.012), a malignant diagnosis (93.2% vs 90.4%), and longer operative time (393 min vs 348 min, p < 0.001). In a case-matched cohort, mortality (2% vs 2.4%, p = 0.618) and severe morbidity (38.2% vs 34.6%, p = 0.128) were comparable between patients with and without FJ tubes. FJ tube placement was associated with higher overall morbidity (46% vs 38.6%, p = 0.002), superficial wound infection (6.3% vs 2.9%, p = 0.001), and return to the operating room (16.7% vs 12.5%, p = 0.016). In a subgroup of patients with anastomotic leak, FJ was associated with shorter hospital stay (20.1 days vs 24.3 days, p = 0.046). CONCLUSION: These mixed findings support selective rather than routine FJ tube placement during esophagectomy.

Predictors of Failed Transcystic Laparoscopic Common Bile Duct Exploration: Analysis of Multicenter Integrated Health System Database.

BACKGROUND: The aim of this study is to report our experience with laparoscopic common bile duct exploration (LCBDE) and validate the experts' opinion about anatomical predictors of failed transcystic LCBDE (TLCBDE) approach. METHODS: Patients undergoing LCBDE at Kaiser Permanente Southern California hospitals (2005-2015) were included. Predictors of failed TLCBDE were identified using bivariate analysis. RESULTS: Of 115 LCBDE, 89.6% were TLCBDE and 10.4% through choledochotomy. Success rate, morbidity, and length of hospital stay were 83.5%, 6.1%, and 3.8 days respectively. Only stone size:cystic duct ratio >1 (35% versus 63%, P = .044) was associated with failure of TLCBDE. In accordance with experts' opinion, there was a suggestive association of stone size ≥6 mm, cystic duct ≤4 mm, multiple stones, and proximal stone location with failure; however, these did not reach statistical significance. CONCLUSION: LCBDE is an effective and safe mean of clearing common bile duct stones at community hospitals of an integrated health system. Previously cited contraindications for TLCBDE are not absolute, but rather predictors of failure.

Complex Ventral Hernias: A Review of Past to Present.

With the incidence of ventral hernias increasing, surgeons are faced with greater complexity in dealing with these conditions. Proper knowledge of the history and the advancements made in managing complex ventral hernias will enhance surgical results. This review article highlights the literature regarding complex ventral hernias, including a shift from a focus that stressed surgical technique toward a multimodal approach, which involves optimization and identification of suboptimal characteristics.

Same-Day versus Conventional Different-Day Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: A Multi-Center Retrospective Study.

Same-day endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy (LC) could potentially reduce hospital length of stay (HLOS). Patients undergoing same-day procedures (N = 164) between 2012 and 2014 were compared with different-day procedures performed in the second half of 2014 (N = 276), in the Kaiser Permanente Southern California database. Both groups had comparable baseline characteristics. ERCP success rate (97.5% vs 93.5%), overall postoperative morbidity (3.66% vs 3.99%), and retained stones (2.5% vs 5.8%) were not different between groups (P > 0.05); however, HLOS was shorter in the same-day group (2.99 ± 2.34 vs 3.84 ± 2.52 days, P < 0.001). Morbidity, procedure success, and HLOS were not different in the same-day group, whether ERCP was performed before or after LC (P > 0.05). In the same-day group, those undergoing single anesthesia had higher BMI (40.1 ± 10.8 vs 30.3 ± 6.6) and were more likely to have gastric bypass (30% vs 0%) than those undergoing separate anesthesia sessions (P < 0.01). Longer HLOS (4.8 ± 3.5 vs 2.9 ± 2.2 days) and higher estimated blood loss (65 ± 90 mL vs 20 ± 29 mL) were also associated with the single-anesthetic session (P < 0.01). ERCP performed on the same day of LC reduces HLOS without increasing morbidity. This approach does not affect postoperative morbidity and ERCP success rate, whether ERCP was performed before or after LC.