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Introduction: Biliary dyskinesia is typically defined as a gallbladder ejection fraction (EF) <35% on hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (CCK-HIDA) testing. Cholecystectomy often leads to resolution of associated biliary colic symptoms. Alternatively, there is a subset of symptomatic patients with normal gallbladder EF on CCK-HIDA. It has been proposed that pain with CCK injection is more predictive of symptom resolution after cholecystectomy than low gallbladder EF. We reviewed our experience with pediatric patients with positive CCK provocation testing and a normal gallbladder EF in the absence of gallstones. Materials and Methods: We retrospectively reviewed the records of all pediatric patients with normal hepatobiliary iminodiacetic acid EFs (35%-80%) and pain with CCK injection at a tertiary care center between 2016 and 2020. Age, gender, body mass index (BMI), CCK-HIDA results, and pathology analysis were noted. Short- and long-term resolution of symptoms was determined by patient self-reporting at a mean of 3 weeks and 46 months, respectively. Results: Seventeen patients met inclusion criteria. Average age was 15.1 years (range, 12-17 years) with median BMI 24.9 (± 4.9 kg/m2). Mean CCK-HIDA EF was 56.3% (± 11.4%). In total, 62.5% of patients had evidence of chronic cholecystitis and/or cholesterolosis on pathology analysis. Of patients available for short-term and long-term postoperative follow-up, 80% and 83% reported complete or near complete resolution of symptoms, respectively. Conclusions: Normokinetic biliary dyskinesia is poorly understood but appears to be associated with chronic inflammation and cured by surgical intervention. Laparoscopic cholecystectomy results in resolution of symptoms for a majority of patients and should be considered in those with pain with CCK injection despite normal imaging studies. Clinical Trial Registration Number: 1657640-2.
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Discinesia Biliar , Colecistectomía Laparoscópica , Adolescente , Niño , Humanos , Discinesia Biliar/cirugía , Colecistectomía , Colecistectomía Laparoscópica/efectos adversos , Colecistectomía Laparoscópica/métodos , Colecistoquinina , Iminoácidos , Dolor , Estudios RetrospectivosRESUMEN
BACKGROUND: Biliary dyskinesia generally refers to a hypofunctioning gallbladder with an ejection fraction (EF) of <35% on hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (CCK-HIDA testing). In adults, biliary hyperkinesia has a defined association with biliary colic symptoms and can be relieved with surgical intervention. This clinical entity has not been well described in children or adolescents. In fact, only recently have we seen biliary hyperkinesia on HIDA at our centers. To that end, we reviewed our recent experience with adolescents who have presented and been treated for this unusual clinical entity. METHODS: With IRB approval, we retrospectively reviewed the records of all patients with abnormally high HIDA EFs (>80%) cared for by the pediatric surgery services at two tertiary care centers over the span of a three-year period. Age, sex, BMI, CCK-HIDA results, and preoperative testing and post-operative pathology were noted. Resolution of symptoms was determined by subjective patient self-reporting at postoperative visit. RESULTS: Eighteen patients met inclusion criteria. Average age 15.7 (range, 10-17 years), median BMI 27.3 (±8.2). Fifteen patients were female and 3 were male. Average CCK-HIDA EF was 91.6% (±5.2), 82.4% of the patients had evidence of chronic cholecystitis and/or cholesterolosis on pathology. Postoperatively, 82.4% of the patients available for follow up (n=17) reported complete or near complete resolution of symptoms. CONCLUSIONS: Biliary hyperkinesia is an emerging clinical entity in children and adolescents and has a similar presentation to biliary hypokinesia. While the pathophysiologic mechanism of pain is not fully elucidated, laparoscopic cholecystectomy appears to provide a surgical cure for these patients and should be considered in the differential for the patient with an unremarkable workup and history suggestive of biliary colic.
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BACKGROUND: In 2011, about 30,000 people died in motor vehicle collisions (MVCs) in the United States. We sought to evaluate the causes of prehospital deaths related to MVCs and to assess whether these deaths were potentially preventable. METHODS: Miami-Dade Medical Examiner records for 2011 were reviewed for all prehospital deaths of occupants of 4-wheeled motor vehicle collisions. Injuries were categorized by affected organ and anatomic location of the body. Cases were reviewed by a panel of 2 trauma surgeons to determine cause of death and whether the death was potentially preventable. Time to death and hospital arrival times were determined using the Fatality Analysis Reporting System (FARS) data from 2002 to 2012, which allowed comparison of our local data to national prevalence estimates. RESULTS: Local data revealed that 39% of the 98 deaths reviewed were potentially preventable (PPD). Significantly more patients with PPD had neurotrauma as a cause of death compared to those with a nonpreventable death (NPD) (44.7% vs. 25.0%, P =.049). NPDs were significantly more likely to have combined neurotrauma and hemorrhage as cause of death compared to PPDs (45.0% vs. 10.5%, P <.001). NPDs were significantly more likely to have injuries to the chest, pelvis, or spine. NPDs also had significantly more injuries to the following organ systems: lung, cardiac, and vascular chest (all P <.05). In the nationally representative FARS data from 2002 to 2012, 30% of deaths occurred on scene and another 32% occurred within 1 h of injury. When comparing the 2011 FARS data for Miami-Dade to the remainder of the United States in that year, percentage of deaths when reported on scene (25 vs. 23%, respectively) and within 1 h of injury (35 vs. 32%, respectively) were similar. CONCLUSIONS: Nationally, FARS data demonstrated that two thirds of all MVC deaths occurred within 1 h of injury. Over a third of prehospital MVC deaths were potentially preventable in our local sample. By examining injury patterns in PPDs, targeted intervention may be initiated.
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Accidentes de Tránsito/mortalidad , Heridas y Lesiones/mortalidad , Adulto , Causas de Muerte , Médicos Forenses , Bases de Datos Factuales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
Heterotopic gastric mucosa (HGM) is a rare, but acknowledged source of gastrointestinal pathology in pediatric patients. Sometimes clinically confused with a Meckel's diverticulum, HGM diagnosis is often made postoperatively by pathology. We present a case of jejunal HGM with a positive technetium pertechnetate scan in the right lower quadrant that resembled a Meckel's diverticulum.
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Coristoma/diagnóstico por imagen , Mucosa Gástrica , Enfermedades del Yeyuno/diagnóstico por imagen , Divertículo Ileal/diagnóstico , Niño , Coristoma/cirugía , Diagnóstico Diferencial , Femenino , Gastrectomía , Humanos , Enfermedades del Yeyuno/cirugía , Tomografía de Emisión de PositronesRESUMEN
In recent years, the use of negative pressure wound therapy (NPWT) devices has changed the way sternal wound infections are being managed. It is not uncommon for deep sternal wound infections to occur together with mediastinal or even pleural collections requiring underwater seal drainage. In these patients in whom there is a communication between the pleural and mediastinal cavities, the concomitant use of an NPWT device negates the pressure gradient within the pleural and mediastinal drains, allowing suppurative fluid to stagnate. We present a novel technique to address this limitation of NPWT devices in patients with sternal wound infections that communicate with a pleural collection.
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Tubos Torácicos , Drenaje/instrumentación , Mediastinitis/terapia , Terapia de Presión Negativa para Heridas/instrumentación , Derrame Pleural/terapia , Esternotomía/efectos adversos , Infección de la Herida Quirúrgica/terapia , Anciano , Drenaje/efectos adversos , Diseño de Equipo , Femenino , Humanos , Mediastinitis/diagnóstico , Mediastinitis/microbiología , Terapia de Presión Negativa para Heridas/efectos adversos , Derrame Pleural/diagnóstico , Derrame Pleural/microbiología , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/microbiología , Resultado del TratamientoRESUMEN
There continues to be debate about the routine use of deep vein thrombosis (DVT) prophylaxis in burn patients. The concern is that routine prophylaxis may lead to adverse events. The debate hinges on the incidence of DVT and its relation to the risk-benefit ratio. This study seeks to estimate the true rate of DVT in burn patients, and to evaluate possible risk factors to its development. The Nationwide Inpatient Sample was queried for all patients with age ≥18 years with ICD-9 codes for burn injuries. Demographic data, comorbidities, burn data, length of stay, total charges, procedures, presence of central venous catheter, and mortality were recorded. Patients were classified based on the presence of DVT. Student's t-test, χ test, and logistic regression were performed. 36,638 burn patients were identified. DVT rate was 0.8%. Patients with DVT were older, had longer hospitalizations, more procedures, and higher charges. On logistic regression, black race, TBSA ≥20%, history of previous venous thrombotic events, blood transfusion, and mechanical ventilation were the significant factors associated with DVT. Patients with DVT were almost twice as likely to die during the admission (P = .011). This is the largest series to date examining the risk factors for DVT in burn patients. DVT developed in approximately 0.8% of burn patients. Black race, TBSA ≥20%, blood transfusions, and mechanical ventilation were associated with approximately 2-fold odds of developing DVT. Identification of these additional risk factors may allow targeted patient prophylaxis. Additionally, patients with DVT incurred higher total charges and longer hospitalization.
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Quemaduras/complicaciones , Trombosis de la Vena/epidemiología , Adulto , Negro o Afroamericano/estadística & datos numéricos , Factores de Edad , Anciano , Transfusión Sanguínea , Quemaduras/etnología , Quemaduras/patología , Bases de Datos Factuales , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Respiración Artificial , Factores de Riesgo , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Infection is the leading cause of death in burn patients. Historically, this was due to burn wound sepsis but pneumonia has now emerged as the most common source. In light of the increasing incidence of multi-drug-resistant organisms, the description of rare infections is paramount in continuing the fight against deadly pathogens. We aim to describe the second case of non-tuberculous mycobacterium (NTM) reported in a burn patient. Difficulties in diagnosis and management will also be highlighted. METHODS: A 70-y-old Caucasian female, with a past medical history for type 2 diabetes mellitus, was transferred to our facility after a house fire. She had sustained a 28% total body surface area (TBSA) flame burn to her neck, torso, and all four extremities. She underwent excision and grafting on hospital day five with multiple subsequent attempts at excision and grafting due to graft loss. On hospital day 14, a tracheostomy was performed. Her hospital course was complicated by ongoing respiratory failure, renal injury, and sepsis. RESULTS: Mycobacterium abscessus was found on blood cultures from central venous catheters and arterial line catheters as well as on tracheal aspirate and bronchoalveolar lavage (BAL) on hospital day 86. Imaging then revealed multiple pulmonary nodular densities with patchy ground-glass opacities. After multiple adjustments to the antibiotic regimen, tigecycline, clarithromycin, and cefoxitin therapy was started. She remained on this regimen for almost 4 wks. Her other infections included Acinetobacter baumanii treated with tobramycin and colistin, as well as Candida albicans for which she received fluconazole. Ultimately, her clinical state worsened leading to withdrawal of care. CONCLUSIONS: Sepsis NTM is rare in burn patients with only one other case described in the English-language literature. Both cases reflect differences in diagnosis and management. This highlights the need to discuss rare infections in an attempt to broaden the clinician's awareness of such pathogens, as well as to collaborate to form a consensus about their management.
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Quemaduras/complicaciones , Infecciones por Mycobacterium no Tuberculosas/diagnóstico , Infecciones por Mycobacterium no Tuberculosas/patología , Mycobacterium/aislamiento & purificación , Sepsis/etiología , Sepsis/patología , Acinetobacter/aislamiento & purificación , Infecciones por Acinetobacter/complicaciones , Infecciones por Acinetobacter/diagnóstico , Infecciones por Acinetobacter/microbiología , Infecciones por Acinetobacter/patología , Anciano , Antibacterianos/uso terapéutico , Sangre/microbiología , Líquido del Lavado Bronquioalveolar/microbiología , Quemaduras/cirugía , Candida albicans/aislamiento & purificación , Candidiasis/complicaciones , Candidiasis/diagnóstico , Candidiasis/microbiología , Candidiasis/patología , Enfermedad Crítica , Femenino , Humanos , Unidades de Cuidados Intensivos , Mycobacterium/clasificación , Infecciones por Mycobacterium no Tuberculosas/microbiología , Neumonía Bacteriana/complicaciones , Neumonía Bacteriana/diagnóstico , Neumonía Bacteriana/microbiología , Neumonía Bacteriana/patología , Sepsis/microbiología , Tráquea/microbiología , Insuficiencia del TratamientoRESUMEN
BACKGROUND: Since their inception in the late 1970s, trauma networks have saved thousands of lives in the prehospital setting. However, few recent works have been done to evaluate the patients who die in the field. Understanding the epidemiology of these deaths is crucial for trauma system performance evaluation and improvement. We hypothesized that specific patterns of injury could be identified and targeted for intervention. METHODS: Medical examiner reports in a large, urban county were reviewed including all trauma deaths during 2011 that were not transported to a hospital (i.e., died at the scene) or dead on arrival. Age, sex, date of death, mechanism, and list of injuries were recorded. An expert panel reviewed each case to determine the primary cause of death, and if the patient's death was caused by potentially survivable injuries or nonsurvivable injuries. RESULTS: A total of 512 patients were included. Patients were 80% male, died mostly of blunt (53%) and penetrating (46%) causes, and included 21% documented suicides. The leading cause of death was neurotrauma (36%), followed by hemorrhage (34%), asphyxia (15%), and combined neurotrauma/hemorrhage (15%). The anatomic regions most frequently injured were the brain (59%), chest (54%), and abdomen (35%). Finally, 29% of the patient deaths were classified as a result of potentially survivable injuries given current treatment options, mostly from hemorrhage and chest injuries. CONCLUSION: More than one of every five trauma deaths in our study population had potentially survivable injuries. In this group, chest injuries and death via hemorrhage were predominant and suggest targets for future research and implementation of novel prehospital interventions. In addition, efforts targeting suicide prevention remain of great importance. LEVEL OF EVIDENCE: Epidemiologic study, level V.
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Servicios Médicos de Urgencia/estadística & datos numéricos , Mortalidad , Adulto , Factores de Edad , Causas de Muerte , Femenino , Florida/epidemiología , Humanos , Masculino , Estudios Retrospectivos , Factores Sexuales , Población Urbana/estadística & datos numéricos , Heridas y Lesiones/mortalidadRESUMEN
BACKGROUND: Precocious puberty treatment traditionally meant anxiety-provoking monthly depot injections until the advent of the annually implanted histrelin capsule. This study is the first to evaluate the surgical and anesthetic aspects of histrelin implantation for precocious puberty. METHODS: All cases from one surgeon at a tertiary pediatric hospital were reviewed for patient age, anesthetic type, technical difficulties, and complications. RESULTS: From 12/2007 to 3/2013, 114 cases (49% implantations, 25% removals/re-implantations, 25% removals) were performed. Local anesthesia was employed in 100% of non-general anesthesia cases (n=109, 96%), augmented by inhaled N2O in 49%. Five patients (4%) underwent general anesthesia: three neurologically-impaired and two coordinated with scheduled MRIs. Procedural difficulties (n=18, 16%) included implant fracture during removal (n=16/58 removals, 28%). Fracture never occurred during implantation. Three children (3%) suffered complications. One infection was treated with antibiotics, and two implants were removed for systemic allergic reaction. Six children (5%) had unscheduled post-operative checks for pain (n=3, 3%), allergy to elastic dressing (n=2, 2%), or rash (n=1, 1%). Mean charges for general anesthesia were $10,188±1292 versus $528±147 for N2O or local alone (p<0.0001). CONCLUSION: While histrelin implantation is straightforward, removal presents technical challenges. Local anesthesia, with possible N2O supplementation, is well-tolerated and introduces substantial resource and cost savings.
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Implantes de Medicamentos/administración & dosificación , Hormona Liberadora de Gonadotropina/análogos & derivados , Pubertad Precoz/tratamiento farmacológico , Anestesia General , Anestesia Local , Anestésicos por Inhalación/administración & dosificación , Cápsulas , Niño , Sedación Consciente/métodos , Ahorro de Costo , Remoción de Dispositivos , Implantes de Medicamentos/efectos adversos , Implantes de Medicamentos/economía , Falla de Equipo , Femenino , Hormona Liberadora de Gonadotropina/administración & dosificación , Humanos , Hipersensibilidad/etiología , Infecciones/etiología , Masculino , Óxido Nitroso/administración & dosificación , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Normal saline (NS) is not used for trauma resuscitation because of its potential for acidosis. Lactated Ringer's (LR) is preferred instead. However, the two crystalloids have never been compared in trauma patients. We hypothesized that NS would be an acceptable fluid for resuscitation in the trauma patient. In 2011, a Level I trauma center switched resuscitation fluid from LR to NS. Admissions before and after the change were retrospectively reviewed. Demographics, vitals, blood work, and fluid intake were recorded over 24 hours. Acidosis level, stratified by Injury Severity Score (ISS), was compared. Four hundred ten patients were included, 207 in the LR cohort and 203 in the NS. Chloride (LR 105.26 ± 4.75 vs NS 106.48 ± 4.19), base excess (-2.53 ± 3.77 vs -3.28 ± 4.15), pH (7.37 ± 0.08 vs 7.36 ± 0.07), and bicarbonate (22.83 ± 3.45 vs 21.65 ± 5.06) were statistically different but not clinically significant. This was also true when results were stratified by ISS. In addition, there was no difference in the number of blood gases drawn between the groups (584 vs 544, P = nonsignificant). NS resuscitation is a safe, viable alternative to LR in the trauma population studied. Its use carries a potentially substantial cost savings on a national level.
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Causas de Muerte , Mortalidad Hospitalaria , Soluciones Isotónicas/uso terapéutico , Resucitación/métodos , Cloruro de Sodio/uso terapéutico , Adulto , Análisis Químico de la Sangre , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resucitación/mortalidad , Estudios Retrospectivos , Lactato de Ringer , Medición de Riesgo , Tasa de SupervivenciaRESUMEN
PURPOSE: This study evaluates the incidence trends and clinical outcomes of children with hepatocellular carcinoma (HCC) and assesses factors predictive of patient survival. METHODS: The Surveillance, Epidemiology, and End Results registry was queried from 1973 to 2009 for all patients between ages 0 and 19 with primary HCC. Demographics, tumor histology, surgical intervention, and patient survival were collected. RESULTS: Overall, 218 patients were identified. The annual age-adjusted incidence was 0.05 cases per 100,000 in 2009. Fibrolamellar subtype tumors were exclusive to children >5years old and exhibited greater survival compared to non-fibrolamellar subtype (57% vs. 28%, respectively, p=0.002). Tumor extirpation for patients with resectable disease significantly improved overall survival at 5years compared to no surgery (60% vs. 0%, respectively, p<0.0001). Overall 5-, 10- and 20-year survival for the entire cohort was 24%, 23%, and 8%, respectively. Independent prognostic factors of lower mortality according to multivariate analysis were surgical resection (hazard ratio (HR)=0.18), non-Hispanic ethnicity (HR=0.52), and local disease at presentation (HR=0.46). CONCLUSION: Over the past four decades, the incidence of HCC has remained relatively stable. Children of Hispanic ethnicity have high mortality rates. However, HCC resection for curative intent significantly improves outcomes.
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Hepatoblastoma/epidemiología , Neoplasias Hepáticas/epidemiología , Adolescente , Niño , Preescolar , Femenino , Hepatectomía , Hepatoblastoma/patología , Hepatoblastoma/cirugía , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Incidencia , Lactante , Recién Nacido , Estimación de Kaplan-Meier , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/cirugía , Masculino , Pronóstico , Grupos Raciales/estadística & datos numéricos , Programa de VERF/estadística & datos numéricos , Tasa de Supervivencia , Resultado del Tratamiento , Estados Unidos/epidemiología , Adulto JovenRESUMEN
Iatrogenic biliary injury is the most significant complication after laparoscopic cholecystectomy. We present our experience with an alternative diagnostic approach using transcatheter cholangiography (TCC) through a Jackson-Pratt (JP) drain and discuss potential benefits and limitations of the technique. From March 2002 to February 2012, 40 patients with major postoperative biliary injury underwent biliary reconstruction at our institution. Mean age was 51.7 ± 18.1 years (range, 19 to 86 years) with 30 (75%) females. Seventeen (42.5%) injuries were detected intraoperatively and in 13 (32.5%) cases, JP drains were placed for biliary drainage. Lesions were classified according to Bismuth grade: I (10 patients [25%]), II (10 patients [25%]), III (six patients [15%]), IV (10 patients [25%]), and V (four patients [10%]). TCC was performed in seven patients with JP drains (53.8%). It fully defined the injury site in three cases of limited magnetic resonance cholangiopancreatography (MRCP) such as common hepatic duct and common bile duct leaks and in four cases (57.1%) that endoscopic retrograde cholangiopancreatography (ERCP) was limited as a result of clipping of the distal common bile duct. TCC showed promising results in cases of limited MRCP and ERCP such as fistulous orifices or leakage. It may represent an alternative adjunct in the diagnostic armamentarium of complex biliary injuries.
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Conductos Biliares/lesiones , Catéteres de Permanencia , Colangiografía/métodos , Colecistectomía Laparoscópica/efectos adversos , Drenaje/instrumentación , Adulto , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica , Conductos Biliares/cirugía , Colangiopancreatografia Retrógrada Endoscópica , Pancreatocolangiografía por Resonancia Magnética , Colecistectomía Laparoscópica/instrumentación , Drenaje/métodos , Femenino , Humanos , Yeyuno/cirugía , Hígado/cirugía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Evaluating the cervical spine in the obtunded trauma patient is a subject fraught with controversy. Some authors assert that a negative computed tomography (CT) scan is sufficient. Others argue that CT alone misses occult unstable injuries, and magnetic resonance imaging (MRI) will alter treatment. This study examines the data in an urban, county trauma center to determine if a negative cervical spine CT scan is sufficient to clear the obtunded trauma patient. METHODS: Records of all consecutive patients admitted to a level 1 trauma center from January 2000 to December 2011 were retrospectively analyzed. Patients directly admitted to the intensive care unit with a Glasgow Coma Scale score ≤13, contemporaneous CT and MRI, and a negative CT reading were included. The results of the cervical spine MRI were analyzed. RESULTS: A total of 309 patients had both CT and MRI, 107 (35%) of whom had negative CTs. Mean time between CT and MRI was 16 d. Of those patients, seven (7%) had positive acute traumatic findings on MRI. Findings included ligamentous injury, subluxation, and fracture. However, only two of these patients required surgical intervention. None had unstable injuries. CONCLUSIONS: In the obtunded trauma patient with a negative cervical spine CT, obtaining an MRI does not appear to significantly alter management, and no unstable injuries were missed on CT scan. This should be taken into consideration given the current efforts at cost-containment in the health care system. It is one of the larger studies published to date.
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Vértebras Cervicales/patología , Trastornos de la Conciencia/patología , Imagen por Resonancia Magnética/estadística & datos numéricos , Traumatismos del Cuello/patología , Procedimientos Innecesarios , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Vértebras Cervicales/diagnóstico por imagen , Trastornos de la Conciencia/diagnóstico por imagen , Femenino , Humanos , Inestabilidad de la Articulación/diagnóstico por imagen , Inestabilidad de la Articulación/patología , Ligamentos/diagnóstico por imagen , Ligamentos/lesiones , Ligamentos/patología , Masculino , Persona de Mediana Edad , Traumatismos del Cuello/diagnóstico por imagen , Sistema de Registros , Estudios Retrospectivos , Tomografía Computarizada por Rayos X/estadística & datos numéricos , Adulto JovenRESUMEN
BACKGROUND/AIMS: Major iatrogenic biliary injury is a potentially life-threatening complication after laparoscopic cholecystectomy. Early diagnosis is essential to improve outcomes, however, to date, there is no consensus regarding the best imaging approach for preoperative assessment of these injuries. METHODOLOGY: From March 2002 to February 2012, 40 patients with postoperative major biliary injury underwent biliary reconstruction at our Institution. Mean age was 51.7 ± 18.1 years (19-86) with 30 (75%) females. Magnetic resonance cholangiopancreatography (MRCP) were compared with different diagnostic modalities and definitive intraoperative findings. RESULTS: Of 40 patients, 10 (25%) had Bismuth type I, 10 (25%) Bismuth type II, 6 (15%) Bismuth type III injury, 10 (25%) Bismuth type IV and, 4 (10%) Bismuth type V. MRCP has similar accuracy to define injury site, but is superior in delineating proximal ductal anatomy that was often not visualized with endoscopic retrograde cholangiopancreatography (ERCP). CONCLUSION: MRCP is a reliable, accurate and readily available diagnostic tool to assess complex biliary injuries. It provides adequate visualization of the proximal and distal biliary trees and may be considered as first-line test in the management of major iatrogenic biliary injuries. Revision of current guidelines for diagnostic approach of this condition is warranted.
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Pancreatocolangiografía por Resonancia Magnética/métodos , Colecistectomía Laparoscópica/efectos adversos , Complicaciones Posoperatorias/cirugía , Cuidados Preoperatorios , Adulto , Anciano , Anciano de 80 o más Años , Colangiopancreatografia Retrógrada Endoscópica , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
AIM: To determine the merits of magnetic resonance cholangiopancreatography (MRCP) as the primary diagnostic test for choledochal cysts (CC's). METHODS: Between 2009 and 2012, patients who underwent MRCP for perioperative diagnosis were identified. Demographic information, clinical characteristics, and radiographic findings were recorded. MRCP results were compared with intraoperative findings. A PubMed search identified studies published between 1996-2012, employing MRCP as the primary preoperative imaging and comparing results with either endoscopic retrograde cholangiopancreatography (ERCP) or operative findings. Detection rates for CC's and abnormal pancreaticobiliary junction (APBJ) were calculated. In addition detection rates for clinically related biliary pathology like choledocholithiasis and cholangiocarcinomas in patients diagnosed with CC's were also evaluated. RESULTS: Eight patients were identified with CC's. Six patients out of them had type IV CC's, 1 had type I and 1 had a new variant of choledochal cyst with confluent dilatation of the common bile duct (CBD) and cystic duct. Seven patients had an APBJ and 3 of those had a long common-channel. Gallstones were found in 2 patients, 1 had a CBD stone, and 1 pancreatic-duct stone was also detected. In all cases, MRCP successfully identified the type of CC's, as well as APBJ with ductal stones. From analyzing the literature, we found that MRCP has 96%-100% detection rate for CC's. Additionally, we found that the range for sensitivity, specificity, and diagnostic accuracy was 53%-100%, 90%-100% and 56%-100% in diagnosing APBJ. MRCP's detection rate was 100% for choledocholithiasis and 87% for cholangiocarcinomas with concurrent CC's. CONCLUSION: After initial ultrasound and computed tomography scan, MRCP should be the next diagnostic test in both adult and pediatric patients. ERCP should be reserved for patients where therapeutic intervention is needed.
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The American Burn Association recommends that patients with toxic epidermal necrolysis-Stevens Johnson syndrome (TEN-SJS) or burn inhalation injuries would benefit from admission or transfer to a burn center (BC). This study examines to what extent those criteria are observed within a regional burn network. Hospital discharge data from 2000 to 2010 was obtained for all hospitals within the South Florida regional burn network. Patients with International Classification of Disease-9th revision discharge diagnoses for TEN-SJS or burn inhalation injury and their triage destination were compared using burn triage referral criteria to determine whether the patients were triaged differently from American Burn Association recommendations. Two hundred ninety-nine TEN-SJS and 131 inhalation injuries were admitted to all South Florida hospitals. Only 25 (8.4%) of TEN-SJS and 27 (21%) of inhalation injuries were admitted to the BC. BC patients had greater length of stay (TEN-SJS 22 vs 10 days; inhalation 13 vs 7) and were more likely to be funded by charity or be self-paid (TEN-SJS 24 vs 9.5%, P = .025; inhalation 44 vs 14%, P < .001), but less likely to hold some form of private or government insurance (TEN-SJS 72 vs 88%, P = .02; inhalation 48 vs 81%, P = .006). TEN-SJS BC patients were more frequently discharged home for self-care (76 vs 50%, P = .006). Non-BC patients were more often discharged to other healthcare facilities (28 vs 0% TEN-SJS, 20 vs 7.4% inhalation). Inappropriate triage may occur in more than 3 out of 4 of the TEN-SJS and inhalation injury patients within our burn network. Unfamiliarity with triage criteria, patient insurance status, and overcoding may play a role. Further studies should fully characterize the problem and implement education or incentives to encourage more appropriate triage.
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Unidades de Quemados/estadística & datos numéricos , Quemaduras por Inhalación/terapia , Derivación y Consulta/estadística & datos numéricos , Síndrome de Stevens-Johnson/terapia , Triaje/normas , Adulto , Factores de Edad , Quemaduras por Inhalación/diagnóstico , Quemaduras por Inhalación/mortalidad , Estudios de Cohortes , Toma de Decisiones , Femenino , Florida , Encuestas de Atención de la Salud , Mortalidad Hospitalaria/tendencias , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Necesidades , Evaluación de Resultado en la Atención de Salud , Estudios Retrospectivos , Medición de Riesgo , Factores Sexuales , Síndrome de Stevens-Johnson/diagnóstico , Síndrome de Stevens-Johnson/mortalidad , Tasa de Supervivencia , Resultado del Tratamiento , Triaje/tendencias , Adulto JovenRESUMEN
Biliary-colonic fistula is a rare complication after laparoscopic cholecystectomy. We present a case of post-cholecystectomy iatrogenic biliary injury that resulted in a fistula between the common hepatic duct and large bowel. Magnetic resonance cholangiopancreatography provided good visualization of injury even with concurrent normal level of alkaline phosphatase. Radiologic findings and surgical management of this condition are discussed in detail.
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Fístula Biliar/etiología , Colecistectomía Laparoscópica/efectos adversos , Enfermedades del Colon/etiología , Enfermedades del Conducto Colédoco/etiología , Fístula Intestinal/etiología , Conductos Biliares/lesiones , Fístula Biliar/diagnóstico por imagen , Fístula Biliar/cirugía , Pancreatocolangiografía por Resonancia Magnética , Enfermedades del Colon/diagnóstico por imagen , Enfermedades del Colon/cirugía , Enfermedades del Conducto Colédoco/diagnóstico por imagen , Enfermedades del Conducto Colédoco/cirugía , Femenino , Humanos , Fístula Intestinal/diagnóstico por imagen , Fístula Intestinal/cirugía , Persona de Mediana Edad , RadiografíaRESUMEN
BACKGROUND: Tumors of the thymus are very rare in the pediatric population. This study examines the current trends and outcomes of children with thymus tumors. METHODS: The Surveillance, Epidemiology and End Results (SEER) registry was queried for all patients <20 y of age with primary thymic malignancies from 1973 to 2008. RESULTS: A total of 73 pediatric patients were identified with malignant thymic tumors. The median age at diagnosis was 13 y old. Among the 20 patients that presented with distant disease, 70% died. Conversely, among the 23 patients that presented with locoregional disease, 70% survived. Although the overall mean survival time was 89 ± 116 mo, 45% of patients died over the study period. Patients with Hodgkin lymphomas and germ cell tumors exhibited the highest survival (76% and 60% at 10 y, respectively). Multivariate analysis was used to identify local or regional tumor stage (odds ratio = 4.5, 95% confidence interval = 1.4-14.5) and surgical resection (OR = 3.8, 95% confidence interval = 1.4-10.8) as independent predictors of survival. CONCLUSIONS: Malignant thymomas and lymphomas are the most common histological variants of pediatric thymus tumors, and patients with Hodgkin lymphomas exhibit the highest survival. Surgery is more commonly performed on malignant thymomas and is an independent prognostic indicator of survival.
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Enfermedad de Hodgkin/mortalidad , Neoplasias de Células Germinales y Embrionarias/mortalidad , Programa de VERF , Neoplasias del Timo/mortalidad , Adolescente , Tumor Carcinoide/mortalidad , Tumor Carcinoide/cirugía , Carcinoma Neuroendocrino/mortalidad , Carcinoma Neuroendocrino/cirugía , Niño , Preescolar , Femenino , Enfermedad de Hodgkin/cirugía , Humanos , Lactante , Linfoma no Hodgkin/mortalidad , Linfoma no Hodgkin/cirugía , Masculino , Neoplasias de Células Germinales y Embrionarias/cirugía , Pronóstico , Tasa de Supervivencia , Neoplasias del Timo/cirugía , Adulto JovenRESUMEN
PURPOSE: As the population ages, trauma in the elderly is an increasingly recognized source of elderly morbidity. However, previous reviews on the topic provide only broad recommendations. The purpose of this study was to examine the elderly recidivist cohort at an urban trauma center for mechanisms of repeat injury. METHODS: The trauma registry at a major urban trauma center was queried to identify all patients aged 65 and older admitted from 1991-2010. Recidivist admissions were compared to nonrecidivist admissions. Demographics, mechanism of injury, injury location, length of stay, and mortality data were collected. Recidivists' mechanism of injury was compared with their initial mechanism of injury. Descriptive statistics, Student t-test, and a z-rank test of proportions were applied with significance set to P ≤ 0.05. RESULTS: Between 1991 and 2010, 6476 patients aged 65+ were admitted, of which 79 (1.22%) were recidivists. Of these, 64 patients were aged 65 and older for both admissions. Most often, recidivists were male (70% versus 60%) and injured in penetrating trauma (17% versus 7.5%, P = 0.045). Recidivists trended towards more frequent injuries in bicycle collisions (3% versus 1.9%) and all-terrain vehicle (ATV)/motorcycle crashes (6.3% versus 1.7%), but were less likely to be hit by cars (49% versus 36%, P = 0.034). At least two thirds of recidivist patients injured in falls, ATV/motorcycle accidents, and stabbings had previously been injured by the same mechanism. CONCLUSIONS: The overall recidivism rate in the elderly population is low. Nevertheless, recidivists were more susceptible to penetrating trauma, ATV/motorcycle collisions, and possibly bicycle accidents. These findings can help design counseling initiatives and injury prevention programs that target specific elderly trauma patients.