Background: Decortication of the lung, either by video-thoracoscopy or thoracotomy is potentially a morbid procedure and has significantly higher mortality compared with other major thoracic procedures. Much of this difference can be attributed to other significant comorbidities and to the non-elective nature of the surgery. Our primary goal was to recognize the preoperative unique characteristics of patients who had postoperative mortality within the first 30 days. Our secondary goal was to build a score system to calculate the odds of death after decortication. Methods: Patients who had undergone either partial or total pulmonary decortication were retrospectively identified from the 2015-2017 databases of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and were employed for this analysis. Multivariable regression models were used to evaluate the possible association of multiple risk factors with postoperative death. Factors that remained significant in the multivariable regression analysis were used to develop the Decortication Prognostic Score (DPS). Results: The final study population consisted of 2,315 patients. The overall observed mortality rate was 5.6%. The greatest independent risk factor for increased 30-day mortality in multivariable logistic regression analysis was disseminated cancer, followed by age ≥65 years, ventilator dependence, active hemodialysis, open wound or wound infection, partially or totally dependent preoperative functional status, preoperative systemic inflammatory response syndrome (SIRS), sepsis or septic shock, congestive heart failure (CHF), preoperative need for blood transfusion, dyspnea, and chronic obstructive pulmonary disease (COPD). Afterwards, we developed a prognostic score for calculating the odds of postoperative death. The total score was associated with a stepwise higher risk of postoperative death after decortication. Patients with a score of 1 had an associated mortality of 1.1% [odds ratio (OR): 2, 95% confidence interval (CI): 0.43-9.32, P=0.375], patients with scores 2-3 had an associated mortality of 6.6% (OR: 12.5, 95% CI: 3.04-51.36, P<0.001), and patients with scores ≥4 had an associated mortality of 27.1% (OR: 65.8, 95% CI: 15.86-273.2, P<0.001). Conclusions: Preoperative factors can predict postoperative mortality after decortication. DPS may help guide surgeons with bedside decision making and heighten awareness to patients most likely to be at risk for 30-day re-intubation, failure to wean from ventilator, surgical site infections, prolong length of stay and higher mortality after decortication.
Cholecystocolonic fistulas (CCF) are a rare but significant complication of biliary disease, frequently presenting as gallstone ileus. Although there is no one agreed-upon procedure, enterolithotomy appears to be the initial treatment of choice; with a subsequent cholecystectomy performed ~4-8 weeks later. Alternatively, a patient may undergo a single-stage procedure, at which time an enterolithotomy, cholecystectomy and fistula closure are performed. Herein, we describe two patients with chronic cholecystitis and subsequent development of CCF with differing presentations. We report the clinical, radiographic and intraoperative findings and discuss the surgical treatment options for each patient, respectively.
Background: Clean neck operations (thyroidectomies, parathyroidectomies, and lymph node resection) are among the most common procedures performed in the United States. Surgical site infections (SSIs) after clean neck operations are rare, but the consequences are devastating and often life-threatening. The aim of this study was to develop a score that will identify patients at high risk for developing a SSI after a clean neck procedure. Materials and Methods: Patients with either thyroidectomies, parathyroidectomies, or lymph node resection of the neck were identified from the 2016 and 2017 databases of the American College of Surgeons National Surgical Quality Improvement Program and were used for this analysis. Our primary goal was to build a scoring system with which we will be able to identify patients at high risk for SSI after a clean neck operation. Results: Of a total of 99,877 patients, 72,719 patients had a thyroidectomy, 22,043 patients had parathyroidectomy, and 5,115 patients had lymph node resection of the neck. Multivariable logistic regression identified the following independent risk factors associated with post-operative SSI: male gender (adjusted odds ratio [aOR], 1.25; 95% confidence interval [CI], 1.03-1.51), diabetes mellitus (aOR, 1.34; 95% CI, 1.07-1.67), smoking (aOR, 1.66; 95% CI, 1.36-2.04), pre-operative steroid use (aOR, 1.75; 95% CI, 1.21-2.53), cancer diagnosis (aOR, 1.44; 95% CI, 1.17-1.77), radical lymphadenectomies (aOR, 2.94; 95% CI, 2.16-4), and total operative time ≥198 minutes (aOR, 2.25; 95% CI, 1.82-2.78). Afterward, we developed a prognostic score for calculating the odds of having post-operative SSI. One point was allotted for each of the aforementioned factors, except lymphadenectomies where two points were allotted, and operative time was excluded. Our score was associated with a stepwise higher risk of post-operative SSI after a clean neck operation. Conclusions: Pre-operative and intra-operative factors can predict which patients undergoing a clean neck surgery may develop SSI. Our prognostic score may help guide surgeons identify patients at high-risk for SSI after clean neck surgery and these patients might benefit from prophylactic use of antibiotic agents.
Surgical Wound Infection , Databases, Factual , Humans , Logistic Models , Male , Operative Time , Risk Factors , Surgical Wound Infection/epidemiology , Surgical Wound Infection/etiology , United States
BACKGROUND: Bowel perforation from biliary stent migration is a serious potential complication of biliary stents, but fortunately has an incidence of less than 1%. CASE SUMMARY: We report a case of a 54-year-old Caucasian woman with a history of Human Immunodeficiency virus with acquired immunodeficiency syndrome, chronic obstructive pulmonary disease, alcoholic liver cirrhosis, portal vein thrombosis and extensive past surgical history who presented with acute abdominal pain and local peritonitis. On further evaluation she was diagnosed with small bowel perforation secondary to migrated biliary stents and underwent exploratory laparotomy with therapeutic intervention. CONCLUSION: This case presentation reports on the unusual finding of two migrated biliary stents, with one causing perforation. In addition, we review the relevant literature on migrated stents.
BACKGROUND: Strongyloides stercoralis is an intestinal nematode parasite classified as a soil-transmitted helminth, endemic in tropical and subtropical regions. Strongyloides stercoralis can remain dormant for decades after the initial infection. CASE: We describe a patient who was diagnosed with Strongyloides stercoralis infection three weeks after a left inguinal hernia repair and discuss approaches to prevention, diagnosis, and treatment. CONCLUSIONS: Physicians in the United States often miss opportunities to identify patients with chronic strongyloidiasis. Symptoms may be vague and screening tests have limitations. We review current strategies for diagnosis and treatment of chronic intestinal strongyloidiasis in immigrant patients who have significant travel history to tropical regions and discuss the clinical features and management of the infection.
