A rare occurrence of a poorly differentiated large cell neuroendocrine carcinoma of the gallbladder: A case report and review of the literature.

INTRODUCTION: Neuroendocrine carcinoma (NEC) of the gallbladder is a rare entity with much of the surgical strategy and management mirroring that of adenocarcinoma of the gallbladder. In contrast to gallbladder adenocarcinoma, however, it tends to be a more aggressive and lethal malignancy associated with a short survival after the time of diagnosis. Furthermore, due to its rarity, there are no consensus guidelines for its management. PRESENTATION OF CASE: We present the case of a 73-year-old female who presented with acute cholecystitis and was found to have a poorly differentiated large cell NEC of the gallbladder after laparoscopic cholecystectomy. She was treated with adjuvant chemotherapy and has shown no evidence of cancer recurrence on three-year follow up. DISCUSSION: Surgical resection is the cornerstone of curative treatment for gallbladder NEC. Management may include simple cholecystectomy, extended cholecystectomy, radical cholecystectomy, or palliative cholecystectomy. It is unclear whether lymphadenectomy confers a survival benefit. Adjuvant chemotherapy with platinum-based regimens, on the other hand, has been associated with increased survival rates. Radiation, immunotherapy, somatostatin analogs and targeted therapy have also been used for treatment. CONCLUSION: NEC of the gallbladder is extremely rare, aggressive, and carries a dismal prognosis. Further studies are needed to develop the optimal treatment approach to increase survival rates and establish best practices to manage these patients.

Traumatic extraperitoneal bladder rupture in the absence of pelvic fracture in a patient with pelvic organ prolapse: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Traumatic bladder rupture is a rare occurrence. It is more likely to occur following blunt injury and is associated with pelvic fractures in patients presenting with hematuria. We present a unique case of an extraperitoneal bladder rupture in a female after sustaining a minor fall in the absence of a pelvic fracture. PRESENTATION OF CASE: The patient is a morbidly obese female with a history of vaginal vault prolapse who reported profuse vaginal bleeding and lower abdominal and suprapubic pain shortly after falling off of her bed. The patient showed no signs of hemodynamic instability and genital bleeding was ruled out in the emergency department. A Computed Tomography (CT) cystogram confirmed bladder rupture confined to the extraperitoneal space without any evidence of pelvic fractures. DISCUSSION: Blunt traumatic extraperitoneal bladder rupture is typically associated with concomitant pelvic fracture. These injuries tend to occur as a result of high-impact motor vehicle or motorcycle collisions and are associated with an increased morbidity and mortality. CONCLUSION: Dedicated bladder imaging should be considered in blunt abdominopelvic trauma patients presenting with hematuria in the absence of pelvic fracture when the patient's underlying medical conditions or comorbidities increase the risk of bladder rupture. Our patient's history of pelvic organ prolapse placed her at an increased risk of traumatic injury to the bladder.

Emergency Medical Service Transport Time and Trauma Outcomes at an Urban Level 1 Trauma Center: Evaluation of Prehospital Emergency Medical Service Response.

BACKGROUND: The use of helicopter emergency medical services (HEMS) for trauma patients has been debated since its introduction. We aim to compare outcomes for trauma patients transported by ground EMS (GEMS) vs. HEMS using raw and adjusted mortality in a level 1 trauma center. METHODS: A 6-year retrospective cohort study utilizing our level 1 trauma center registry for patients transferred by GEMS or HEMS was performed. Demographics and outcome measures were compared. Raw and adjusted mortality was evaluated. Adjusted mortality was determined incorporating confounders, including patient demographics, comorbid conditions, mechanism of injury, injury severity score (ISS), Glasgow Coma Scale score, and EMS transport time. Chi-square, multivariable logistic regression, and independent sample T-test were utilized with significance, defined as P < .05. RESULTS: Of 12 633 patients, 10 656 were transported via GEMS and 1977 with HEMS. Mean age was 55 for GEMS and 40 for HEMS (P < .001). Mean ISS was 9.29 and 11.73 for GEMS and HEMS (P < .001). Mean Revised Trauma Score was higher (less severe) for GEMS vs. HEMS (7.6 vs. 7.12, P < .001). Mean transport times for GEMS and HEMS was 39.45 vs. 47.29 minutes (P = .02). Raw mortality was 2.55% (307/10 656) for GEMS and 6.78% (134/1977) for HEMS. Adjusted mortality revealed a 16.6% increased mortality for GEMS compared to HEMS (adjusted odds ratio = 1.166, 95% CI: .815-1.668). CONCLUSIONS: Air-lifted trauma patients were younger, more severely injured, and more hemodynamically unstable and required longer transport time but experienced lower adjusted mortality. Future research is needed to investigate whether reducing transport times and augmenting the advanced care already implemented by HEMS crews can improve outcomes.

Utility of the Marshall & Rotterdam Classification Scores in Predicting Outcomes in Trauma Patients.

BACKGROUND: Traumatic Brain Injury (TBI) is a leading cause of mortality in the trauma population. Accurate prognosis remains a challenge. Two common Computed Tomography (CT)-based prognostic models include the Marshall Classification and the Rotterdam CT Score. This study aims to determine the utility of the Marshall and Rotterdam scores in predicting mortality for adult patients in coma with severe TBI. METHOD: Retrospective review of our Level 1 Trauma Center's registry for patients ≥ 18 years of age with blunt TBI and a Glasgow Coma Scale (GCS) of 3-5, with no other significant injuries. Admission Head CT was evaluated for the presence of extra-axial blood (SDH, EDH, SAH, IVH), intra-axial blood (contusions, diffuse axonal injury), midline shift and mass effect on basilar cisterns. Rotterdam and Marshall scores were calculated for all patients; subsequently patients were divided into two groups according to their score (< 4, ≥ 4). RESULTS: 106 patients met inclusion criteria; 75.5% were males (n = 80) and 24.5% females (n = 26). The mean age was 52. The odds ratio (OR) of dying from severe TBI for patients in coma with a Rotterdam score of ≥ 4 compared to < 4 was OR = 17 (P < 0.05). The odds of dying from severe TBI for patients in coma with a Marshall score of ≥ 4 versus < 4 was OR = 11 (P < 0.05). CONCLUSION: Higher scores in the Marshall classification and the Rotterdam system are associated with increased odds of mortality in adult patients in come from severe TBI after blunt injury. The results of our study support these scoring systems and revealed that a cutoff score of < 4 was associated with improved survival.

A systematic review of the causes and prevention strategies in reducing gun violence in the United States.

BACKGROUND: Approximately 100 lives are lost each day as a result of gun violence in the United States (US) with civilian mass shootings increasing annually. The gun violence rate in the US is almost 20 times higher than other comparable developed countries and has the most gun ownership per capita of any nation in the world. Understanding the causes and risk factors are paramount in understanding gun violence and reducing its incidence. METHODS: A literature search of all published articles relating to gun violence and mass shootings in the US was conducted using the Medline and PMC databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used in conducting this study. Rayyan statistical software was utilized for analysis. Statistical significant was defined as p < .05. RESULTS: Of the initial 2304 eligible manuscripts identified, 22 fulfilled our selection criteria. A variety of common causal and contributory factors were identified including but not limited to mental illness, suicidal ideation, intimate partner violence, socioeconomic status, community distress, family life, childhood trauma, current or previous substance abuse, and firearm access. CONCLUSION: Gun violence is pervasive and multi-factorial. Interventions aimed at reducing gun violence should be targeted towards the most common risk factors cited in the literature such as access, violent behavioral tendencies due to past exposure or substance abuse, and mental illness including suicidal ideation.

Current Trends of Women Surgeon Speakers at National Trauma Surgery Conferences: The Trauma House Is Improving.

BACKGROUND: An invitation to speak at a national meeting represents the advancement of one's career and indicates acceptance and the attention of the scientific community. Studies have revealed gender disparities across medical and surgical society meetings. The purpose of our study was to assess the current trend of women surgeon speakers at major national trauma surgery conferences during the last 4 years (ie, 2016-2019). METHODS: A retrospective analysis of conference programs of major trauma surgery association annual meetings including the American Association for the Surgery of Trauma (AAST), the Eastern Association for the Surgery of Trauma (EAST), and the Western Trauma Association (WTA) was conducted. Our primary outcome was the number and proportion of women surgeon speakers at each conference each year. RESULTS: Twelve conference programs from three national trauma surgery association annual meetings were reviewed. A total of 2029 speakers were included; 608 (30%) of which were female and 1421 (70%) of which were male. The proportion of women speakers ranged from 22.3% to 41.4%. The number of women speakers increased each year from 2016 to 2019: (EAST: 25.2%-39.8%, P = .049; AAST: 27.1%-41.4%, P < .00001, and WTA: 27.8%-33.3%, P = . 0.573). CONCLUSION: The number of women surgeon speakers at national trauma surgery conferences significantly increased from 2016 to 2019. The increase in women trauma surgeon speakers is encouraging and should be celebrated, but organizational leadership should take this information into account while extending invitations to surgeons for speaking opportunities and continue to promote diversity and inclusivity.

The Association of Women Surgeons research grant: An analysis of the first 25 years.

BACKGROUND: The impact of the Association of Women Surgeons (AWS) Research Grant on academic productivity is unknown. METHODS: Grant applications were obtained from AWS archives. Applicant bibliometrics and National Institutes of Health (NIH) grants were identified via public databases. RESULTS: Twenty-four recipients between 1996 and 2020 and 68 nonrecipients between 2012 and 2017 were identified. $596,700 was awarded over the 25 years. Twenty-five percent of recipients subsequently acquired NIH funding amounting to $6,611,927.00, an 885-1008% return on investment. Compared to nonrecipients, grant recipients produced a greater mean number of publications (50.6 versus 36.4; p = 0.05), had a higher h-index (15.92 versus 10.7; p = 0.01), and were cited in higher impact factor journals (6.32 versus 3.9; p = 0.02). CONCLUSIONS: Overall, previous AWS Research Grant recipients were more likely to become more impactful surgeon-scientists, as indicated by a higher post-award rate of NIH funding, total number of publications, and h-index than nonrecipients.

Correction to: Is Extended-Duration (Post-Hospital Discharge) Venous Thromboembolism Chemoprophylaxis Safe and Efficacious in High-Risk Surgery Patients? A Systematic Review.

In the original article, the authors' affiliations and affiliation addresses are inaccurate. They are correct as reflected here.

Is Extended-Duration (Post-Hospital Discharge) Venous Thromboembolism Chemoprophylaxis Safe and Efficacious in High-Risk Surgery Patients? A Systematic Review.

BACKGROUND: The risk of venous thromboembolism (VTE) persists beyond hospitalization in surgical patients, yet post-hospital discharge chemoprophylaxis regimens are not common. The purpose of this study is to systematically review the literature regarding extended-duration (post-hospital discharge) venous thromboembolism chemoprophylaxis and to determine whether it is warranted in high-risk surgical patients, as determined by its safety and efficacy. METHOD: We searched four online databases for articles evaluating extended-duration (post-hospital discharge) VTE chemoprophylaxis regimens in surgical patients between the years January 2000 and February 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used. GRADE methodology and the Cochrane Risk of Bias Assessment Tool for Randomized Controlled Trials were used to grade the quality of evidence and assess risk of bias. RESULTS: Nineteen studies with 10,544 patients were analyzed. The duration for extended-duration VTE chemoprophylaxis ranged from 7 to 42 days. In our study cohort, high-risk patients not prescribed extended-duration VTE chemoprophylaxis had a mean VTE incidence rate of 12.23%, while patients receiving 28-30 days of chemoprophylaxis had a mean VTE incidence rate of 4.37% (p = 0.006). The risk of bleeding events did not correlate with the duration of chemoprophylaxis. CONCLUSION: Extended-duration VTE chemoprophylaxis in high-risk surgical patients decreased the incidence of thrombotic complications without increasing the risk of bleeding events. Further research is needed to establish guidelines for the optimal duration of VTE chemoprophylaxis in high-risk surgical patients. LEVEL OF EVIDENCE: III.

Disparities in Adult and Pediatric Trauma Outcomes: a Systematic Review and Meta-Analysis.

BACKGROUND: Although safeguards requiring emergency care are provided regardless of a patient's payor status, disparate outcomes have been reported in trauma populations. The purpose of this systematic review and meta-analysis was to determine whether race/ethnicity or insurance status had an effect on mortality and to systematically present the literature in the adult and pediatric trauma populations during the last decade. METHODS: An online search of PubMed, Cochrane Library, Google Scholar, and SAGE Journals was performed for publications from January 2009 to March 2019. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used. The GRADE Working Group criteria were utilized to assess the evidence quality. A meta-analysis was conducted to compare mortality between insured/uninsured and Caucasian/non-Caucasian patients. RESULTS: Our search revealed 680 publications that qualified for evaluation. Of these, 41 were included in the final analysis. Twenty-six studies included adults only, nine studies included pediatric patients only, and six studies evaluated both. Twelve studies evaluated the effects of race/ethnicity, 18 examined insurance status, and 11 investigated both. Uninsured patients had 22% greater odds of death than insured patients (OR 1.22; CI 1.21-1.24). Non-Caucasian patients had 18% greater risk of death than Caucasian patients (OR 1.18; CI 1.17-1.20). CONCLUSION: Both the adult and pediatric trauma populations suffer outcome disparities based on race/ethnicity and insurance status. Overall, patients without insurance coverage and minority groups (i.e., non-Caucasians) had worse outcomes, as measured by odds of death and all-cause mortality.

Superficial Stab Wound to Zone I of the Neck Resulting in Thyrocervical Trunk Pseudoaneurysm Presented as Recurrent Hemothorax and Successfully Managed by Coil Embolization.

BACKGROUND Thyrocervical trunk pseudoaneurysms are rare complications that have been documented after internal jugular or subclavian venous cannulation. Even less common, these pseudoaneurysms can arise after blunt or penetrating trauma. Clinical hallmarks include an expanding supraclavicular mass with local compressive symptoms such as paresthesias, arterial steal syndrome, and Horner's syndrome. Patients may be asymptomatic, however, or present with overlying ecchymosis or the presence of a new bruit or thrill. With the risk of rupture, thyrocervical trunk pseudoaneurysm is associated with significant morbidity and mortality. CASE REPORT We report the case of a 27-year-old man who presented after sustaining a self-inflicted stab wound to zone I of his neck. Initial examination revealed only a superficial small laceration, but a chest x-ray revealed a pneumothorax, and tube thoracostomy returned 300 mL of bloody output. After resolution of the hemothorax and removal of the thoracostomy tube, the patient reaccumulated blood, requiring a repeat tube thoracostomy. Angiography at that time revealed a pseudoaneurysm of the thyrocervical trunk, and coil embolization was performed to obliterate the pseudoaneurysm. CONCLUSIONS Thyrocervical trunk pseudoaneurysms can be asymptomatic, often have a delayed presentation, and can be life-threatening due to the risk of rupture and subsequent hemodynamic decline or airway compromise. While these pseudoaneurysms are well-known complications of deep penetrating injuries, they can also present following superficial penetrating injury to zone I of the neck. Selective angiography is the imaging modality of choice. Open surgical repair was traditionally the criterion standard for treatment; however, endovascular approaches are minimally invasive, feasible, and safer alternatives with reduced complications and are becoming more common.

Anticoagulant chemoprophylaxis in patients with traumatic brain injuries: A systematic review.

BACKGROUND: Traumatic brain injury (TBI) continues to be a deadly injury. Universally accepted guidelines regarding the use of venous thromboembolism (VTE) chemoprophylaxis in trauma patients presenting with TBI have not been established. The purpose of this review was to identify and review the current literature and present the evidence for anticoagulant chemoprophylaxis regimens in patients with TBI. METHODS: A search of five databases including PubMed, Web of Science, Google Scholar, JAMA Network, and Cochrane Journals was conducted for studies evaluating the safety and efficacy of venous thromboembolism prophylaxis regimens according to the Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group criteria were used for quality of evidence assessment. RESULTS: Seventeen studies were included in this review: 1 randomized controlled trial, 2 prospective observational studies, 10 retrospective reviews, and 5 systematic reviews. Most studies demonstrated that early chemoprophylactic administration is associated with a decreased incidence of VTE in patients with TBI without an increase in intracranial bleed. CONCLUSION: For patients with TBI resulting in intracranial hemorrhages, administration of VTE chemoprophylaxis is warranted for those patients with stable repeat computed tomography scans. Early chemoprophylaxis, at 24 to 72 hours is associated with reduced VTE incidence without a corresponding increase or exacerbation of intracranial hemorrhage in patients with TBI who have a stable repeat head computed tomography scan. More studies are needed to establish guidelines for the safety and efficacy of VTE prophylaxis protocols in adult patients with TBI. LEVEL OF EVIDENCE: Systematic review, level III.

Mild and Moderate Traumatic Brain Injury and Gender-Based Critical Care Outcomes.

BACKGROUND: Traumatic brain injury (TBI) is a major contributor to death and complications. Previous studies have identified gender disparities among trauma patients. This study aims to examine the association between gender and outcomes in TBI patients. STUDY DESIGN AND METHODS: Review of our trauma registry: Patients were classified into groups according to their gender. Demographics extracted from the registry included age, injury severity score (ISS), Glasgow Coma Score (GCS), head abbreviated injury score (AIS), and the presence of an epidural hematoma (EDH). The primary outcome was mortality; secondary outcomes included ICU length of stay (ICU-LOS), craniotomy rate, ventilator-associated pneumonia (VAP), and readmission rates. Significance was defined as p < 0.05. RESULTS: Nine hundred and thirty-five patients with TBI were studied: 62.1% (n = 581) were male and 37.9% (n = 354) were female. There were no differences in GCS, ISS, and head AIS. Males were younger [53 (IQR 30-77) vs. 76 (IQR 49.25-84), p < 0.05] and were more likely to have an EDH (9.6% vs. 4.8%, p = 0.007). Males also had a longer median ICU-LOS [4 days (IQR 2-8) vs. 3 days (IQR 0-5), p < 0.05] and were significantly more likely to require a craniotomy (44.6% vs. 19.2%, p < 0.001). In addition, males were more likely to develop VAP (4.1% vs. 0.8%, p = 0.004). Predicted survival (79.2% vs. 72.9%) and actual mortality rates (4.5% vs. 4.5%) were similar in both genders (p > 0.05). CONCLUSION: In the context of our study, male patients with TBI were significantly younger, were more likely to sustain an EDH, and were also more likely to require a craniotomy, but mortality rates between both genders were similar. The male gender was also associated with a significantly increased ICU-LOS and VAP.

Venous thromboembolism chemoprophylaxis regimens in trauma and surgery patients with obesity: A systematic review.

BACKGROUND: Venous thromboembolism (VTE) continues to be a devastating source of morbidity and mortality in obese patients who suffer traumatic injuries or obese surgery patients. High incidence rates in VTE despite adherence to prevention protocols have stirred interest in new dosing regimens. The purpose of this study was to systematically review the literature and present the existing VTE chemoprophylaxis regimens for obese trauma and surgical patients in terms of efficacy and safety as measured by the incidence of VTE, anti-factor Xa levels, and the occurrence of bleeding events. METHODS: An online search of seven literature databases including PubMed, Excerpta Medica Database, GoogleScholar, JAMA Network, CINAHL, Cochrane, and SAGE Journals was performed for original studies evaluating the safety and efficacy of VTE chemoprophylaxis dosing regimens according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The risk of bias was assessed using the Cochrane Risk of Bias Tool and the quality of evidence was determined using the GRADE Working Group criteria. RESULTS: Of the 5,083 citations identified, 45 studies with 27,717 patients met inclusion criteria. In this group, six studies evaluated weight-based dosing regimens, four used a weight-stratified or weight-tiered strategy, five used a body mass index-stratified approach, 29 assessed fixed-dose regimens, and two used continuous infusions. The majority of the studies evaluated anti-factor Xa levels as their primary outcome rather than reduction in VTE. CONCLUSION: Weight-based and high fixed-dose chemoprophylaxis regimens achieved target anti-Xa concentrations more frequently than standard fixed-dose regimens but were not associated with a reduction in VTE. Additionally, high fixed-dose approaches are associated with increased bleeding complications. Further evaluation with large randomized trials is warranted in trauma and surgery patients with obesity. LEVEL OF EVIDENCE: Systematic review, level III.

Ballistic Axillary Vein Transection: A Case Report.

BACKGROUND Axillo-subclavian vessel injuries were traditionally the result of combat-related trauma encountered by military surgeons. An increase in gun-related violence in our backyards, however, have brought these injuries to our doorsteps. The majority of the available data explores the management of arterial injuries. There is a deficiency in the literature discussing the management of isolated axillo-subclavian venous injuries. CASE REPORT We report the case of a 25-year-old male who presented after sustaining a gunshot wound to his right lateral chest and axillary area. Computed tomography angiography revealed axillary vein transection. Upon emergent operative intervention, vascular control of the hemorrhage was achieved with ligation of the axillary vein. The patient had an uncomplicated postoperative course and follow up in the office was unremarkable. CONCLUSIONS Axillo-subclavian vessel injuries can result in exsanguination and are associated with a significant mortality risk. Early detection and expeditious management are essential for preserving the patient's limb and preventing the loss of life. Isolated axillary vein injuries can be managed in an unstable patient with ligation and is well-tolerated by patients with an evanescent upper extremity edema.

Successful management with endovascular stent graft repair following gunshot wound to the subclavian artery: Case report and literature review.

INTRODUCTION: Penetrating injuries to the subclavian artery are usually the result of gunshot wounds or stab wounds. While subclavian artery injuries are relatively uncommon, vascular injuries due to penetrating trauma are frequently encountered at Trauma Centers. Despite advances in modern medicine, these injuries are associated with a high mortality and can lead to devastating morbidity. PRESENTATION OF CASE: We report a case of a 20-year-old male who presented after sustaining multiple gunshot wounds to his left upper and lower extremities. He underwent an emergent repair of a left axillo-subclavian artery injury via an endovascular approach using a covered self-expanding stent and was discharged after less than a week. DISCUSSION: Historically, open surgical repair was considered the gold standard in the management of subclavian artery injury. However, rapid technological developments and advances in vascular surgery offer alternative management approaches in traumatic vascular surgery. In a select subset of trauma patients with penetrating vascular injuries, a minimally invasive endovascular approach may be an option. Endovascular repairs are associated with shorter operative times, less blood loss, lower complications and also a reduced mortality rate. CONCLUSION: Endovascular stent graft prostheses offer a minimally invasive treatment modality in the management of traumatic penetrating subclavian artery injuries.

Subclavian artery avulsion following blunt trauma: A case report and literature review.

INTRODUCTION: Subclavian artery injuries are rare and are associated with a high morbidity and mortality. The majority of patients with blunt trauma to the subclavian artery succumb to their injury before reaching a hospital. In-hospital mortality remains high. PRESENTATION OF CASE: We report the case of a 30-year-old male who presented with complete traumatic subclavian artery avulsion after a motorcycle collision. He presented in hemorrhagic shock. Temporary hemostatic control was achieved with endovascular balloon occlusion followed by operative intervention. DISCUSSION: Prompt diagnosis and meticulous management including early transfusion, when indicated, are necessary to salvage both the patient's life and limb from such severe injuries. Intra-operative diagnosis of subclavian artery injury is most common due to the hemodynamic instability of most patients with such injuries; however, conventional angiography and computed tomography angiography are useful diagnostic modalities as well. Temporizing measures such as endovascular balloon occlusion to obtain vascular control may serve as a valuable adjunct to surgical repair. CONCLUSION: Repair of a subclavian artery injury is challenging for even the most experienced of surgeons. Endovascular techniques can be therapeutic or used as an adjunct to control bleeding ad allow an open repair.

Life-threatening hemoperitoneum secondary to rupture of a uterine leiomyoma: A case report and review of the literature.

INTRODUCTION: While uterine leiomyomas are the most common pelvic tumors in females, resultant hemoperitoneum is an extremely rare and acute complication which requires emergent intervention and resuscitation. To date, less than one-hundred cases have been reported in the literature. PRESENTATION OF CASE: We report a case of massive hemoperitoneum due to spontaneous rupture of a 20 cm pedunculated leiomyoma in a 74-year-old female who presented as a trauma alert. Rapidly declining hemodynamic status with an ultrasound consistent with extensive hemoperitoneum led to activation of the massive transfusion protocol and an emergent laparotomy. In the operating theater the laparotomy revealed 4 L of blood. She underwent a myomectomy and subsequently, an angiogram and embolization of a bleeding uterine artery. In all, she required transfusion of 26 units of blood. Post operatively she was discharged home on hospital day 13. DISCUSSION: Near fatal hemoperitoneum secondary to a uterine leiomyoma may be due to traumatic or spontaneous rupture of an overlying vein or artery. Leiomyomas greater than 10 cm in size have an increased risk of rupturing. A significant amount of blood can accumulate in the peritoneum resulting in hypovolemic shock. CONCLUSION: Acute complications of uterine leiomyomas requiring surgical intervention are exceptionally rare. Candidates for the massive transfusion protocol must be appropriately and timely identified. Additionally, because surgery is a potential treatment for hemorrhage control in leiomyoma-related hemoperitoneum, surgeons should be aware of such complications.