A unique presentation of perforated duodenal ulcer in a postpartum woman: a case report.

Gallbladder disease and peptic ulcer disease (PUD) can present very similarly, and misdiagnosis can often result because of conflicting symptoms. PUD in pregnancy is relatively rare, in part due to the changes in estrogen and progesterone levels. We present a case of a postpartum female, post operation Day 5, with signs/symptoms, physical exam and laboratory work consistent with acute cholecystitis that was found to have a perforated duodenal ulcer intraoperatively. The authors suggest that a fistula would have resulted with ongoing disease. Bilio-enteric fistulas can often form due to ongoing cholelithiasis disease. Cholecystoduodenal fistulas (CDFs) are the most common fistulas to present. It is possible that the incidence of CDF formation secondary to perforated duodenal ulcers is underestimated due to signs and symptoms not presenting until gallstone ileus is diagnosed.

Ear Molding Therapy: Laypersons' Perceptions, Preferences, and Satisfaction with Treatment Outcome.

This study investigates laypersons' perceptions of congenital ear deformities and preferences for treatment, particularly with ear molding therapy-an effective, noninvasive, yet time-sensitive treatment. METHODS: Laypersons were recruited via crowdsourcing to view photographs of normal ears or one of the following ear deformities, pre- and post-molding: constricted, cryptotia, cupped/lopped, helical rim deformity, prominent, and Stahl. Participants answered questions regarding perceptions and treatment preferences for the ear. Statistical analyses included multiple linear and logistic regressions and Wilcoxon signed-rank tests. RESULTS: A total of 983 individuals participated in the study. All deformities were perceived as significantly abnormal, likely to impair hearing, and associated with lower psychosocial quality of life (all P < 0.001). For all deformities, participants were likely to choose ear molding over surgery despite the logistical and financial implications of ear molding (all P < 0.02). Participants were significantly more satisfied with the outcome of ear molding in all deformities compared with control, except constricted ears (all P < 0.002, except Pconstricted = 0.073). Concern for hearing impairment due to ear deformity was associated with increased likelihoods of seeing a physician (P < 0.001) and choosing ear molding despite treatment logistics and costs (all P < 0.001). CONCLUSIONS: Laypersons perceived all ear deformities as abnormal and associated with low psychosocial quality of life. Despite logistical and financial implications, laypersons generally desired molding therapy for ear deformities; treatment outcomes were satisfactory for all deformities except constricted ears. Timely diagnosis of this condition is crucial to reaping the benefits of ear molding therapy.

Volar Cortical Integrity in Non-Operatively Treated Adult Distal Radius Fractures.

Background: We sought to independently validate published data that volar cortical integrity (VCI) is an independent predictor of maintenance of closed reduction in a series of non-surgically treated distal radius fractures, while simultaneously investigating previously reported predictors of instability. Our null hypothesis was that volar cortical integrity would not affect maintenance of reduction. Methods: Four hundred thirty-three adult distal radius fractures were screened from our Orthopedic database with 112 meeting inclusion criteria. Two groups were determined on the basis of maintenance of reduction (MOR) or loss of reduction (LOR) at 5-6 weeks post-reduction. Bivariate analysis was applied to previously published instability factors along with VCI. A forward stepwise logistic regression was then used to identify instability factors that, as a group, are most predictive of outcome. Results: Results of 112 patients were collected. Reduction was maintained in 62 patients (55.35%) at 5-6 weeks Biivariate analysis showed a statistically significant difference in volar cortical integrity between the 2 groups (80.6% MOR vs 59.2% LOR). Forward stepwise logistic regression analysis of subgroups revealed that post-reduction radial height and VCI were together statistically significant in the model. The presence of VCI, post-reduction radial height greater than or equal to ulnar neutral at the time of initial reduction resulted in a 67.8% successful MOR. Conclusions: We were able to confirm the importance of volar cortical integrity as a predictor of successful maintenance of reduction in non-surgically managed distal radius fractures. When combined with post-reduction radial height greater than or equal to ulnar neutral at the time of initial reduction, it showed a 67.8% MOR with non-operative management in our data-set.

Ventricular shunt complications in patients undergoing posterior vault distraction osteogenesis.

PURPOSE: The primary objective of this study is to investigate post-operative morbidity and shunt revision rates of patients with shunt-dependent hydrocephalus (SDH) undergoing posterior vault distraction osteogenesis (PVDO) compared to patients undergoing conventional posterior vault reconstruction (PVR). METHODS: A retrospective case-controlled cohort analysis of all patients with SDH undergoing PVDO and PVR for syndromic or complex craniosynostosis was performed. Demographic information, perioperative variables, distraction protocols, and shunt-related complications-infection, surgical revision of shunt, increased length of stay (LOS), and readmission within 90 days of surgery-were compared using the appropriate statistical tests. RESULTS: Fourteen patients with ventricular shunts who underwent PVDO and eight patients with shunts who underwent PVR were identified. Shunt-related complication rates were significantly higher with PVDO (n = 5) compared to PVR (n = 0), p = 0.0093. Among the five patients who suffered complications, the most common were shunt infection (n = 4), shunt malfunction (n = 4), and wound infections (n = 3). All patients with complications required additional operations for shunt revision and/or replacement; four patients required multiple takebacks for such procedures, with an average of three additional procedures per patient. CONCLUSIONS: In complex or syndromic craniosynostosis patients who have previously undergone ventricular shunting, PVDO is associated with higher shunt-related complications and need for additional procedures when compared to traditional PVR. While the benefits of PVDO in the treatment of syndromic craniosynostosis are well documented, the risks of PVDO in the face of a VP shunt must be considered. Further investigation into patient-specific risk factors and risk reduction strategies is warranted.

Improved operative and recovery times with mini-thoracotomy aortic valve replacement.

BACKGROUND: The small incisions of minimally invasive surgery have the proposed benefit of less surgical trauma, less pain, and faster recovery. This study was done to compare minimally invasive techniques for aortic valve replacement, including right anterior mini-thoracotomy and mini-sternotomy, to conventional sternotomy. METHODS: We retrospectively reviewed 503 patients who underwent isolated aortic valve replacement at our institution from 2012 to 2015 using one of three techniques: 1) Mini-thoracotomy, 2) Mini-sternotomy, 3) Conventional sternotomy. Demographics, operative morbidity, mortality, and postoperative complications were compared. RESULTS: Of the 503 cases, 267 (53.1%) were mini-thoracotomy, 120 (23.8%) were mini-sternotomy, and 116 (23.1%) were conventional sternotomy. Mini-thoracotomy patients, compared to mini-sternotomy and conventional sternotomy, had significantly shorter bypass times [82 (IQ 67-113) minutes; vs. 117 (93.5-139.5); vs. 102.5 (85.5-132.5), respectively (p < 0.0001)], a lower incidence of prolonged ventilator support [3.75% vs. 9.17 and 12.9%, respectively (p = 0.0034)], and required significantly shorter ICU and postoperative stays, resulting in an overall shorter hospitalization [6 (IQ 5-9) days; vs. 7 (5-14.5); vs 9 (6-15.5), respectively (p < 0.05)]. Incidence of other postoperative complications were lower in the mini-thoracotomy group compared to mini-sternotomy and conventional sternotomy, without significance. Minimally invasive techniques trended towards better survival [mini-thoracotomy 1.5%, mini-sternotomy 1.67%, and conventional sternotomy 5.17% (p = 0.13)]. CONCLUSIONS: Minimally invasive aortic valve replacement approaches are safe, effective alternatives to conventional sternotomy. The mini-thoracotomy approach showed decreased operative times, decreased lengths of stay, decreased incidence of prolonged ventilator time, and a trend towards lower mortality when compared to mini-sternotomy and conventional sternotomy.

In Situ Hinge Technique for the Frontal Bandeau for the Correction of Metopic Craniosynostosis Reduces Operative Time.

BACKGROUND AND PURPOSE: Treatment of metopic craniosynostosis often involves bitemporal expansion of the anterior cranium. This report compares perioperative variables of a surgical technique in which the fronto-orbital bandeau is bent in situ to traditional fronto-orbital advancement and remodeling (FOAR). METHOD/DESCRIPTION: Six patients undergoing the hinge technique were compared to the senior author's 6 most recent conventional FOARs. Study and control cohorts were reasonably well matched for age and sex; only those with nonsyndromic, single-suture metopic synostosis were included. Perioperative variables such as OR time, blood loss, hardware costs, length of stay, and perioperative complications were compared between groups using unpaired t tests. RESULTS: Operative time was significantly decreased when the hinge technique was utilized, with a mean operative time of 159 ±â€Š14.0 minutes for hinge patients and 193 ±â€Š33.8 minutes for nonhinge patients (P = 0.049). Hardware was also significantly decreased from an average of 2.2 ±â€Š1.0 plates and 35 ±â€Š13.8 screws in nonhinge patients to 1 plate and 20 screws in each hinge patient (P < 0.02), for an average hardware saving of $2990 per hinge surgery (P = 0.019). Estimated blood loss, length of stay, and perioperative complications were not significantly different between groups. All patients in both groups had Whitaker 1 outcomes in short-term follow-up. CONCLUSIONS: The hinge technique for the treatment of metopic synostosis is associated with a statistically significant decrease in operative time, hardware utilization, and hardware cost. Perioperative outcomes were similar between the hinge technique and traditional FOAR in the short term, and additional follow-up is needed to determine whether the 2 have similar long-term outcomes.

Femoral cannulation: a safe vascular access option for cardiopulmonary bypass in minimally invasive cardiac surgery.

Femoral cannulation during cardiopulmonary bypass has become a common approach for many cardiac procedures and serves as an important access option, especially during minimally invasive cardiac surgery. Opponents, however, argue that there is significant risk, including site-specific and overall morbidity, which makes the use of this modality dangerous compared to conventional aortoatrial cannulation techniques. We analyzed our institutional experience to elucidate the safety and efficacy of femoral cannulation. All data were collected from a single hospital's cardiac surgery database. A total of 346 cardiac surgeries were evaluated from September 2012 to September 2013, of which 85/346 (24.6%) utilized a minimally invasive approach. Of the 346 operations performed, 72/346 (20.8%) utilized femoral cannulation while 274/346 (79.2%) used aortoatrial cannulation. Stroke occurred in 1/72 (1.39%) after femoral cannulation, specifically, in a conventional sternotomy patient, while it occurred in 6/274 (2.19%) [p=0.67] after aortoatrial cannulation. When comparing postoperative complications between the femoral cannulation and aortoatrial cannulation groups, the rates of atrial fibrillation [10/72 (13.9%) versus 46/274 (16.8%), p=0.55], renal failure [2/72 (2.78%) versus 11/274 (4.01%), p=0.62], prolonged ventilation time [4/72 (5.56%) versus 27/274 (9.85%), p=0.26] and re-operation for bleeding [3/72 (4.17%) versus 13/274 (4.74%), p=0.84] showed no significant difference. Selective femoral cannulation provides a safe alternative to aortoatrial cannulation for cardiopulmonary bypass and is especially important when performing minimally invasive cardiac surgery. When comparing aortoatrial and femoral cannulation, we found no significant difference in the postoperative complication rates and overall mortality.