Major Oncologic Surgery at a Community Hospital.

There is a national trend to refer patients requiring complex oncologic surgery to tertiary high-volume cancer centers. However, this presents major access challenges to Hawai'i patients seeking care. The purpose of this study is to demonstrate that complex oncologic surgery can be safely performed at community hospitals like those in Hawai'i. From July 2007 to December 2014, 136 patients underwent complex oncologic procedures at a community hospital in Hawai'i by a single general surgeon. Cases included esophagogastric, hepatobiliary, pancreatic, rectal, and retroperitoneal resections. A database of patients was created from information extracted from the EPIC database. Complications were evaluated using the Clavien-Dindo grading system. There was 0.7% mortality rate (grade V complication). The major morbidity rate was 12.5%, including 10.3% grade III complications and 2.2% grade IV complications. The median length of stay for all operations was 8 days. The mean estimated blood loss for all operations was 708 cc. There was a 2.9% hospital readmission rate within 30 days of initial discharge, and a 5.1% reoperation rate. Complex oncologic procedures can be safely performed at a low-volume community hospital, with outcomes similar to those from high-volume cancer centers.

Congenital Mesenteric Defect: An Uncommon Cause of Bowel Obstruction.

Congenital mesenteric defects can lead to internal hernias which may result in a bowel obstruction. They are very rare among the adult population, comprising only 0.2%-0.9% incidence rate of all small bowel obstructions. A 40 year old woman presented to the Emergency Department with abdominal pain.Computed tomography scan was obtained and showed a small bowel obstruction.After failed conservative management with bowel rest and nasogastric tube decompression, the patient underwent diagnostic laparoscopy.An internal hernia was identified though a congenital mesenteric defect at the level of the sigmoid colon. The hernia was reduced and the defect closed. When a patient presents with abdominal pain the diagnosis of a congenital mesenteric defect with internal hernia should be considered with subsequent emergent surgical exploration.

Thrombophilia testing has limited usefulness in clinical decision-making and should be used selectively.

Management of venous thromboembolism (VTE) includes evaluation for hypercoagulable state, especially if the VTE occurs in young patients, is recurrent, or is associated with a positive family history. These laboratory tests are costly, and surprisingly, there is little evidence showing that testing leads to improved clinical outcomes. Evidence based on observational prospective studies suggests that optimal duration of anticoagulation should be based on clinical risks resulting in VTE, such as transient, permanent, and idiopathic or unprovoked risks, and less on abnormal thrombophilia values. Thrombophilia screening is important in a subgroup of clinical scenarios, such as when there is clinical suspicion of antiphospholipid antibody syndrome, heparin resistance, or warfarin necrosis; with thrombosis occurring in unusual sites (such as mesenteric or cerebral deep venous thrombosis); and for pregnant women or those seeking pregnancy or considering estrogen-based agents. Thrombophilia screening is not likely to be helpful in most cases of first-time unprovoked VTE in the setting of transient risks, active malignant disease, deep venous thrombosis of upper extremity veins or from central lines, two or more VTEs, or arterial thrombosis with pre-existing atherosclerotic risk factors. The desire by both patient and physician for a scientific explanation of the clotting event may alone lead to testing, and if so, it should be with the understanding that an abnormal test result will likely not change management, and normal results do not accurately exclude a thrombophilic defect because there are likely factors yet to be discovered. Such false assumptions may lead to shorter durations of treatment than are optimal.