Costal margin reconstruction for slipping rib syndrome: Outcomes of more than 500 cases and advancements beyond earlier sutured repair technique.

Objectives: To evaluate results of sutured repair for slipping rib syndrome (SRS), identify failure points, and discuss technique modifications to improve outcomes through costal margin reconstruction (CMR). Methods: Patients undergoing repair of SRS between February 2019 and February 2024 at an academic referral institution were retrospectively analyzed. Pain scores, quality of life, pain medication use, and reoperations were evaluated pre- and postoperatively at 1 and 6 months. In patients failing sutured repair we identified specific failure points and devised a new CMR technique to overcome them. Subsequent CMR patients were followed at 1, 6, 12, 18, and 24 months using the same outcome measures. Results: Four hundred forty-nine patients underwent repair. Two hundred forty-one patients underwent sutured repair with revision required in 66. Median time to revision was 14 months. CMR was developed and performed in 247 patients. In CMR patients, preoperative mean pain score of 7.5 out of 10 dropped postoperatively to 4.0, 2.5, 1.9, 1.3, and 0.9 at 1, 6, 12, 18, and 24 months, respectively (P < .001). Mean quality of life of 38% improved to 73%, 83%, 88%, 93%, and 95% at the same intervals (P < .001). Preoperatively, 29% of patients chronically used opioid medications. Opioid use dropped postoperatively to 11%, 4%, 4%, 0%, and 0% at the same intervals. Use of nonopioid medications followed a similar pattern. One CMR patient required full revision. Conclusions: SRS is a debilitating, but correctable disorder. Improved pain and quality of life, reduction in chronic opioid use, and freedom from revision surgery suggest that CMR should be considered the standard operation for SRS.

Minimally Invasive Repair of Adult Slipped Rib Syndrome Without Costal Cartilage Excision.

BACKGROUND: Slipped rib syndrome (SRS) is a painful disorder caused when 1 or more of the 8th-10th false ribs become abnormally mobile. Established treatment modalities include analgesia, intercostal nerve injection, and costal cartilage excision. No definitive surgical correction of SRS without cartilage excision has been previously described. We aimed to determine whether a nonexcisional repair technique in affected adults could demonstrate significant relief from SRS using standardized outcome measures. METHODS: We performed a retrospective review of cases of SRS treated at our institution in 2019. We obtained data by survey before and after sutured 10th rib fixation, using a self-reported rating scale from 0-10 at defined intervals. Surveyed outcome measures were compared pre- and postoperatively using the Wilcoxon signed rank sum test. The use of neural modulating, narcotic, and nonsteroidal antiinflammatory drug medications was also compared pre- and postoperatively using McNemar's test where applicable. RESULTS: SRS was diagnosed using clinical examination alone in 42 adults and repaired in 29 patients. Median postoperative improvement in pain at 1 and 6 months was 75% (P < .001) and 80% (P < .001), respectively. Improvements in other outcome measures were similar. In patients who took pain medications preoperatively, narcotics were discontinued at 1 month by 100%, neural modulators by 86%, and nonsteroidal antiinflammatory drugs by 92% (all P values < .001). Pain medication use remained minimal at 6 months in 23 (79%) of patients completing follow-up. CONCLUSIONS: Minimally invasive slipped rib repair in adults provides significant relief of SRS, offering a useful alternative to costal cartilage excision. It is well tolerated and effective.

Postpartum rupture of the posteromedial papillary muscle.

We report a case of postpartum severe mitral regurgitation caused by papillary muscle rupture in a female with normal coronary arteries. The etiology of papillary muscle rupture was endocarditis from puerperal fever. Clinical stabilization was achieved with extracorporeal membrane oxygenation (ECMO) followed by mitral valve replacement two days later.

Large subcapsular liver hematoma following single-incision laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVES: Many laparoscopic surgeons are now transitioning from standard multiple-port laparoscopic cholecystectomy to single-incision laparoscopic surgery (SILS) in an attempt to improve cosmetic outcomes and decrease postoperative morbidity. However, little has been published regarding the potential complications of SILS operations. METHODS: We report the case of a patient undergoing SILS cholecystectomy who developed the complication of a large hepatic hematoma, resulting in significant postoperative morbidity, blood transfusion requirement, and reoperation. RESULTS: After an in-depth internal review of the postoperative morbidity of this case, it appears that the causative factor may be instrument shaft torque on the liver surface. CONCLUSION: Single-incision laparoscopic surgery may pose significant and unique risks that warrant additional operative caution. Quantitative comparison of SILS to the gold-standard laparoscopic cholecystectomy is needed to further elucidate definitive benefits and complications of this novel technique.

Combined heart-kidney transplant after CardioWest total artificial heart bridge.

Combined, single-donor, heart and kidney transplant (HKTx) recipients have survival rates comparable with those after heart transplantation alone. Although HKTx provides superior outcomes in patients with dual-organ failure, appropriate single-donor organ pairs are very scarce. Mechanical circulatory support thus seems an attractive option as a bridge to HKTx. We report the case of an adult with end-stage cardiomyopathy and renal failure who was successfully bridged to combined, single-donor HKTx with a total artificial heart. Infectious complications associated with the CardioWest cavity were encountered prior to transplantation. The patient recovered and was discharged 14 days after transplantation. At 4 months post-transplantation, the patient required single-vessel coronary stenting for a high-grade stenosis. At 1 year, he has had no further complications and has excellent function of both transplanted organs. Despite limited availability of same donor organ pairs, patients with combined cardiac and renal failure can be bridged effectively to transplant with the CardioWest total artificial heart.

Laparoscopic repair of colonoscopic perforations: indications and guidelines.

Iatrogenic colonic perforation is one of the most serious potential complications of colonoscopy. Standard management is surgical repair. No prospective data exist to clearly define the indications for laparoscopic repair. We report the largest case series to date of laparoscopic repair of colonoscopic perforations. A retrospective review was performed of all patients undergoing either exploratory laparoscopy with conversion to open repair, or laparoscopic repair of colonoscopic perforation. Exploratory laparoscopy for the attempted repair of colonoscopic perforations was performed in 11 patients at our institution. The mean colonic perforation size was 2.7 cm. Three cases were converted immediately to open laparotomy. A fourth patient that underwent primary laparoscopic repair of a 4-cm tear developed a leak at the repair site, necessitating reoperation. A fifth patient in whom exploratory laparoscopy was unrevealing underwent separate laparotomy for continued sepsis. Six patients underwent successful laparoscopic repair. Most perforations secondary to colonoscopy warrant rapid exploratory laparoscopy. Extensive inflammation or fecal soilage may require colonic diversion. Inability to laparoscopically localize the area of perforation or doubt regarding the security of the repair should prompt conversion to laparotomy. Laparoscopic repair of colonic perforations in experienced hands is a viable alternative to the open approach.

Reverse radial forearm fascial flap with radial artery preservation.

The reverse radial forearm fascial (RRFF) flap is widely used in soft-tissue reconstruction of the hand. The traditional RRFF flap incorporates the radial artery from the forearm and is perfused by retrograde flow through the palmar arch. In patients with an abnormal Allen test because of an incomplete palmar arch, the traditional RRFF flap is contraindicated unless a vein graft is used to reconstruct the radial artery. A simpler alternative approach for hand reconstruction in such patients is a distally based RRFF flap based on radial artery perforators, which preserves the radial artery. We used RRFF flaps based on radial artery perforators in five patients who had palmar or dorsal soft-tissue loss. All five recovered full hand function, and only one had any complications (full-thickness skin graft loss at recipient site). The RRFF flap based on distal radial artery perforators is suitable for thin coverage of soft-tissue defects in hands with either a complete or an incomplete palmar arch.

Radioactive seed localization for excision of non-palpable in-transit metastatic melanoma.

We report the case of a 73-year-old who presented with multiple, small, in-transit melanoma nodules located in her right lower extremity below her knee. Positron emission tomography detected two additional non-palpable subcutaneous lesions posterior and medial to the area of previous wide local excision. A novel approach of radioactive seed localization was employed to guide the surgeon to successful surgical resection of all metastatic disease. To our knowledge, the application of radioactive seed localization to melanoma has not been previously reported.

Histologic severity of appendicitis can be predicted by computed tomography.

HYPOTHESIS: A regression model based on computed tomographic (CT) findings alone can accurately predict the histologic severity of acute appendicitis in patients who have a high disease likelihood. DESIGN: Retrospective study. SETTING: Mayo Clinic in Scottsdale, Ariz. PATIENTS: Consecutive sample of 105 patients (50 women and 55 men, aged 15-89 years) undergoing nonincidental appendectomy within 3 days of nonfocused abdominal CT. INTERVENTIONS: Computed tomographic scans and histologic features were retrospectively reinterpreted. Each patient's histologic and CT findings were scored by standardized criteria. An ordinal logistic regression model was constructed with a subset of CT findings that statistically correlated best with the final histologic features. Predicted severity values were then generated from the model. MAIN OUTCOME MEASURE: Agreement between predicted and actual histologic severity, using weighted kappa measurement. RESULTS: Computed tomography variables used in the model were fat stranding, appendix diameter, dependent fluid, appendolithiasis, extraluminal air, and the radiologist's overall confidence score. The weighted kappa measurement of agreement between predicted and actual histologic severity was 0.75, with a 95% confidence interval between the values of 0.59 and 0.90. CONCLUSIONS: Computed tomographic findings, when used with the regression model developed from this pilot study, can accurately predict the histologic severity of acute appendicitis in patients initially seen with a high clinical suspicion of the disease. These findings provide a platform from which to prospectively test the model.