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Median arcuate ligament (MAL) syndrome (MALS) is a rare condition caused by compression of the celiac artery by the MAL. Symptoms include abdominal pain, nausea, and weight loss. Rarely, the MAL can compress both the celiac artery and the superior mesenteric artery (SMA). We describe the case of a young man with MALS involving the celiac artery and SMA. Laparoscopic release of the MAL was performed, and the patient had resolution of his symptoms at 6 months of follow-up. A review of the literature identified only six cases of MALS involving the SMA and celiac artery, making this a rare occurrence.
ABSTRACT
Acute mesenteric ischemia from thromboembolic occlusion is a life-threatening emergency associated with a high mortality rate. Prompt diagnosis and intervention are vital to preserve viable bowel and prevent mortality. In the past decade, a shift has occurred toward minimally invasive alternatives such as endovascular therapies. We present a case of acute mesenteric ischemia from superior mesenteric artery thrombosis treated promptly with the Penumbra suction thrombectomy device (Penumbra Inc).
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OBJECTIVES: The opioid epidemic is a multifactorial issue, which includes pain mismanagement. Resident physician education is essential in addressing this issue. We aimed to analyze the effects of an educational intervention on the knowledge and potential prescribing habits of emergency medicine (EM), general surgery (GS), and internal medicine residents (IM). METHODS: Resident physicians were provided with educational materials and were given pre-tests and post-tests to complete. Descriptive statistics were used to analyze pre-test and post-test responses. Chi-squared analysis was used to identify changes between the pre-tests and post-tests. A p < 0.05 value was considered statistically significant. Results: Following the educational intervention, we observed improvement in correct prescribing habits for acute migraine management among emergency medicine residents (from 14.8% to 38.5%). Among general surgery residents, there was a significant improvement in adherence to narcotic amounts determined by recent studies for sleeve gastrectomy (p= 0.01) and laparoscopic cholecystectomy (p= 0.002). Additionally, we observed a decrease in the number of residents who would use opioids as a first-line treatment for migraines, arthritic joint pain, and nephrolithiasis. DISCUSSION: Resident physicians have an essential role in combating the opioid epidemic. There was a significant improvement in various aspects of opioid-related pain management among emergency medicine, internal medicine, and general surgery residents following the educational interventions. We recommend that medical school and residency programs consider including opioid-related pain management in their curricula.
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BACKGROUND: Sternoclavicular joint (SCJ) osteomyelitis is a rare pathology requiring urgent intervention. Several operative approaches have been described with conflicting reports. Here, we present a multi-institutional study utilizing multiple surgical pathways for SCJ reconstruction. METHODS: A multi-institutional retrospective cohort study was conducted to identify patients who underwent surgical repair for sternoclavicular osteomyelitis between 2008 and 2019. Patients were stratified according to reconstruction approach: single-stage reconstruction with advancement flap and delayed-reconstruction with flap following initial debridement. Demographics, operative approach, type of reconstruction, and postoperative outcomes were analyzed. RESULTS: Thirty-two patients were identified. Mean patient age was 56.2±13.8 years and 68.8% were male. The average body mass index (BMI) was 30.0±8.8 kg/m2. The most common infection etiologies were intravenous drug use and bacteremia (both 25%). Fourteen patients (43.8%) underwent one-stage reconstruction and 18 (56.2%) underwent delayed twostaged reconstruction. Both single and delayed-stage groups had comparable rates of reinfection (7.1% vs. 11.1%, respectively), surgical site complications (21.4% vs. 27.8%), readmissions (7.1% vs. 16.6%), and reoperations (7.1% vs. 5.6%; all P>0.05). The single-stage reconstruction group had a significantly lower BMI (26.2±5.7 kg/m2 vs. 32.9±9.1 kg/m2; P<0.05) and trended towards shorter hospital length of stay (11.3 days vs. 17.9 days; P=0.01). CONCLUSIONS: Both single and delayed-stage approaches are appropriate methods with comparable outcomes for reconstruction for SCJ osteomyelitis. When clinically indicated, a single-stage reconstruction approach may be preferable in order to avoid a second operation as associated with the delayed phase, and possibly shortening total hospital length of stay.
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BACKGROUND: Elderly and frail patients undergo open emergency colectomies and are at greater risk for complications. The relationship between frailty and open emergent colectomies is yet unexplored. OBJECTIVE: The purpose of this study was to evaluate the relationship between frailty and outcomes after open emergent colorectal surgery. DESIGN: Using the American College of Surgeons National Quality Improvement Program database, a validated modified frailty index was used, along with logistic regression, to assess the relationship between frailty and outcomes. MAIN OUTCOME MEASURES: Outcomes included mortality (primary), Clavien-Dindo Complication Grade >3, reintubation, ventilator >48 hours, and reoperation (secondary). RESULTS: The rates for 30-day mortality, Clavien-Dindo Grade >3, reintubation, ventilator > 48 hours, and reoperation in our cohort were 16.6%, 36.9%, 8.6%, 23.9%, and 15.0%, respectively. There was a statistically significant increase in prevalence of all outcomes with increasing frailty. LIMITATIONS: A causal relationship between frailty and complications cannot be established in a retrospective analysis. Also, extrapolation of our data to reflect outcomes beyond 30 days must be done with caution. CONCLUSIONS: Frailty is a statistically significant predictor of mortality and morbidity after open emergent colectomies and can be used in an acute care setting.
Subject(s)
Colectomy/adverse effects , Frailty/epidemiology , Frailty/mortality , Postoperative Complications/epidemiology , Adult , Aged , Aged, 80 and over , Databases, Factual , Female , Frail Elderly , Humans , Logistic Models , Male , Middle Aged , Postoperative Complications/mortality , Reoperation/methods , Retrospective Studies , Risk AssessmentABSTRACT
BACKGROUND: In a parallel demographic phenomenon, the elderly and obese populations will become a larger part of our population and surgical practices. The elderly obese surgical risk profile is not clearly defined, although studies have confirmed their independent negative effect on surgical outcomes. Benign foregut surgery is a relatively common complex procedure performed on this demographic and warrants deeper investigation into outcomes. We investigate the synergistic effect of age and body mass index (BMI) on the outcomes of benign foregut surgery. METHODS: Data from National Surgical Quality Improvement Program were collected for all patients undergoing foregut surgery from 2005 to 2012. Subjects were over 18 years of age and 16 BMI. Primary and secondary outcomes were 30-day mortality and overall 30-day morbidity, respectfully. Binary logistic regression models were used to assess independent and interactive effects of age and BMI. RESULTS: A total of 19,547 patients had an average age and BMI of 57 and 29.7, respectively. Sample 30-day mortality was 0.32 %. Every 10-year age increase led to a 46 % increased odds of mortality. BMI showed a bimodal distribution with underweight and morbidly obese patients having increased mortality. The effect of BMI only became apparent with increasing age. CONCLUSIONS: Both age and BMI are independent predictors of mortality; only older patients experienced the bimodal BMI effect. Therefore, increasing age and BMI have a synergistic effect on outcomes after foregut operations.