Multiple Internal Hernias: A Complication of Laparoscopic Roux-en-Y Gastric Bypass.

Introduction: Internal hernias are the most common cause of small bowel obstruction following laparoscopic Roux-en-Y gastric bypass surgery (LRYGBP) with four distinct types. Herein, we report the clinical course of a patient with two independent hernias at the Petersen's space and a rarer subtype at the jejunojejunal window. A high index of suspicion for less common subtypes of internal hernias and the possibility of multiple, simultaneous internal hernias is critical. Case Description: We describe the case of a 52-year-old female with a history of LRYGBP who presented with abdominal pain and emesis due to an internal hernia at Peterson's defect, requiring subsequent laparoscopic repair. On postoperative day three, the patient presented again with recurrent abdominal pain and emesis. Repeat exploratory laparoscopy found a separate internal hernia involving the jejunojejunal window with the previously repaired Petersen's defect intact. Discussion: This case illustrates a unique scenario of a patient post-LRYGBP with multiple internal hernias at the Peterson's space and the less common jejunojejunal window, which was missed during the index surgery. Failure to identify simultaneous hernias may result in additional invasive intervention and further morbidity. Conclusion: Multiple less-common variants of internal hernias may present simultaneously following LRYGBP.

The Scan, the Needle, or the Knife? National Trends in Diagnosing Stage I Lung Cancer.

OBJECTIVE: Indeterminate lung nodules have been increasingly discovered since the expansion of lung cancer screening programs. The diagnostic approach for suspicious nodules varies based on institutional resources and preferences. The aim of this study is to analyze factors associated with diagnostic modalities used for early-stage non-small cell lung cancer (NSCLC). METHODS: The National Cancer Database was queried for all patients with stage I NSCLC from 2004 to 2015. Four diagnostic modalities were identified, including clinical radiography alone (CRA), bronchial cytology (BC), procedural biopsy (PB), and surgical biopsy (SB). A multivariable multinomial logistic regression was used to assess associations of patient demographics, cancer characteristics, and facility characteristics with these modalities. RESULTS: Of 250,614 patients, 4,233 (1.7%) had CRA, 5,226 (2.1%) had BC, 147,621 (59.9%) had PB, and 93,534 (37.3%) had SB. Older patients were more likely to receive CRA (adjusted odds ratio [ORadj] = 5.3) and less likely to receive SB (ORadj = 0.73). Black patients were less likely to receive SB (ORadj = 0.83) and more likely to receive BC (ORadj = 1.31). Private insurance was associated with SB (ORadj = 1.11), whereas Medicaid was associated with BC (ORadj = 1.21). Patients more than 50 miles from the facility were more likely to undergo SB (ORadj = 1.25 vs PB; ORadj = 1.30 vs CRA; ORadj = 1.38 vs BC). Patients receiving SB had shorter days from diagnosis to treatment (23.0 vs 53.5 to 64.7 for other modalities, P < 0.001). CONCLUSIONS: Diagnostic SB to confirm early-stage NSCLC was associated with younger age, greater travel distance, and shorter time to treatment in comparison with other modalities. Black race and non-private insurance were less likely to be associated with SB.

Challenges in the Methodology for Health Disparities Research in Thoracic Surgery.

Research on health disparities in thoracic surgery is based on large population-based studies, which is associated with certain biases. Several methodological challenges are associated with these biases and warrant review and attention. The lack of standardized definitions in health disparities research requires clarification for study design strategy. Further inconsistencies remain when considering data sources and collection methods. These inconsistencies pose challenges for accurate and standardized downstream data analysis and interpretation. These sources of bias should be considered when establishing the infrastructure of health disparities research in thoracic surgery, which is in its infancy and requires further development.

Integrating Endovascular and Operative Intervention in Trauma.

BACKGROUND: Patterns of utilization of the hybrid operating room (hybrid-OR) in trauma have not been described. The aim of this study was to describe the sequencing and integration of endovascular and operative interventions in trauma using a hybrid-OR. MATERIALS AND METHODS: This is a single-center, retrospective cohort study of trauma patients who underwent both endovascular and operative intervention (2013-2019). Patients were separated into four groups based on procedure patterns: concomitant-linked (C-L), concomitant-independent, serial-linked (S-L) and serial-independent (S-I). The groups were defined as follows: C-L - related endovascular and operative interventions in the same OR; concomitant-independent - unrelated interventions in the same OR; S-L - related interventions in separate ORs; S-I - unrelated interventions in separate ORs. Patient characteristics, procedures performed and time to angiography in each group were analyzed. RESULTS: Out of 202 patients, most procedures utilizing the hybrid-OR were for hemorrhage control (84.1%) and were performed in a C-L manner (36.1%). Patients in the C-L group were most likely to undergo lower extremity revascularization and received the most transfusions. Patients in the S-L and S-I groups were more severely injured, had greater severe abdominal injury and were more likely to undergo damage control surgery and solid organ interventions, respectively. The C-L group had the highest percentage of patients to undergo angiography within 12 h (77%, P = 0.053). CONCLUSION: The hybrid-OR is an ideal space for hemorrhage control in trauma, but there is room for improvement in the triage of patients with non-compressible torso hemorrhage. Current practice patterns prioritize the hybrid-OR for management of lower extremity injury and are not optimal. Use of the hybrid-OR could be improved by concomitant management of patients with severe abdominal injury requiring damage control surgery.

Outcomes following abdominal trauma in Scotland.

PURPOSE: Traumatic abdominal injury is associated with significant mortality, especially in hemodynamically unstable patients. Trauma management now supports more conservative surgical management with judicious non-operative management. The aim of this study is to use STAG data to characterize abdominal trauma outcomes, focusing on factors that may influence mortality. METHODS: A retrospective analysis of prospectively collected STAG data was queried using AIS codes for Scottish abdominal trauma patients between 2011 and 2015. Patients were divided into non-survivor and survivor groups, reflecting mortality. Following this, outcomes and injury patterns of patients undergoing operative or non-operative management were compared between groups. RESULTS: A total of 1226 were analyzed. The mean age of the cohort was 42.47 ± 19.42 years, with most patients suffering blunt injuries. Non-survivors had more severe injuries to the liver, diaphragm, pancreas, vasculature, and pelvis (p < 0.001, p = 0.005, p = 0.025, p < 0.001, and p < 0.001, respectively). Survivors more often received CT scanning (0.09 [0.03-0.27]) and underwent surgical intervention (57.4% vs 39.7%; p = 0.001). Non-survivors more often had a shorter time till operative intervention (2.6 h vs 6.3 h, p < 0.001). CONCLUSIONS: About 7% of patients in the STAG registry display abdominal injury. Mortality was found to have strong associations with older age, hemodynamic instability, poor neurological status, and head and neck injury. Outcomes may improve with the anticipated creation of the Scottish Trauma System.

Radial versus femoral arterial access for trauma endovascular interventions: A noninferiority study.

BACKGROUND: The majority of endovascular interventions for trauma are performed using transfemoral access (TFA). Transradial access (TRA) is a recently integrated alternative at the authors' institution. This noninferiority study compares the technical success and complication rate of TRA compared with TFA. METHODS: All patients undergoing emergent endovascular interventions between March 2016 and March 2019 were identified from a prospectively maintained database. Data were collected on access type, complications, and procedural success. A noninferiority margin was established from previous randomized trials for technical success (0.475) and complications (0.015). RESULTS: Over 3 years, 96 patients underwent TRA and 335 patients received TFA. The overall technical success rate was 98.1%, without significance based on access strategy (p = 0.078). All femoral arteries and 97.9% (n = 94) of radial arteries were accessed as intended. Complications occurred in 1.0% of TRA and 9.9% of TFA groups (p = 0.002). In the TFA group, complications included access site bleeding, hematoma, pseudoaneurysm, lower limb ischemia, and femoral artery thrombosis (n = 6, 14, 3, 3, and 4, respectively). In the TRA group, complications included radial artery thrombosis (n = 1). Transradial access procedural success and complication rate fell within the lower bound confidence interval of the noninferiority margin, demonstrated the noninferiority of TRA in this data set. CONCLUSION: Transradial access in a cohort of trauma patients undergoing endovascular intervention does not appear to be inferior to TFA in relation to technical success and complications. For patients where groin access may be challenging, TRA is a useful, efficacious, and safe alternative. Longer-term study is required to fully characterize the advantages and disadvantages of TRA compared with TFA. LEVEL OF EVIDENCE: Therapeutic V.

Preoperative Opioid Prescription Patients Do Not Suffer Distinct Outcomes After Bariatric Surgery: a Matched Analysis of Outcomes.

PURPOSE: While over 200 million opioid prescriptions are written annually for chronic pain in the USA, little has been written on the impact of opioids on bariatric surgery, specifically on the effects of prescription opioid use on weight loss post laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS: We completed a matched-cohort, retrospective review in 1176 consecutive patients undergoing primary bariatric surgery at a single institution. Patients were grouped into chronic prescription opioid users (POU), defined as ongoing opioid use for > 3 months at the time of surgery, and opioid-naïve controls (CON), defined as no opioid use prior to surgery. About 130 POU and 130 CON patients were then matched according to preoperative comorbid conditions and demographics. RESULTS: Percent total weight loss was similar at 3 weeks, 3 months, 6 months, 1 year, and 2 years in POU and CON-9.6 ± 5.8 vs 8.9 ± 4.5 (p = 0.057), 18.4 ± 7.2 vs 18.5 ± 7.2% (p = 0.901), 28.0 ± 9.4 vs 27.9 ± 12.9% (p = 0.894), 30.3 ± 13.0 vs 32.8 ± 9.0% (p = 0.387), and 31.4 ± 12.7 vs 36.9 ± 21.3% (p = 0.369), respectively. The 30-day readmission, reoperation, venothrombotic event rate, bleeding rate, and infection rate were similar in POU compared to CON patients. CONCLUSIONS: Complications and weight loss outcomes are similar for prescription opioid users compared to opioid-naïve controls following bariatric surgery. Chronic prescription opioid use is not a contraindication to bariatric surgery.

Improving the safety of resuscitative endovascular balloon occlusion of the aorta - Compliant versus semi-compliant balloon systems.

OBJECTIVES: Resuscitative endovascular balloon occlusion of the aorta is an alternative to resuscitative thoracotomy in non-compressible torso haemorrhage. Low-profile, compliant balloon catheter systems have been developed, which can be deployed without the need for fluoroscopy. However, concern exists for over inflation and aortic injury, especially as compliant balloon material can stretch reducing syringe feedback and limiting the effectiveness of a safety valve. An alternative material would be a semi-compliant balloon material, but its performance is unknown. The aim of this study was to compare the inflation characteristics of compliant versus semi-compliant balloon systems and to determine whether a pressure relief safety valve can be practically applied to a semi-compliant balloon catheter as a safety device. METHODS: This was an ex vivo study using porcine segments of thoracic aorta. The study consisted of two phases. The first phase involved intermittent inflation of six compliant balloon and six semi-compliant balloon balloons until balloon or aortic rupture. In the second phase, six semi-compliant balloons with the pressure-relief valve set at 0.45 atmospheres were inflated in the aortas until the valve release, followed by injection with additional 30 mL. Data including pressure, volume, balloon working length, diameter and circumferential stretch ratio were collected. RESULTS: At failure, mean balloon volume was almost double in compliant balloon group vs semi-compliant balloon group - 49.83 mL (±23.25) and 25.16 mL (±8.93), respectively (p = 0.004), with 36% increase in working length in the compliant balloon group - 81.17 mm (±19.11) vs 59.49 (±4.86) for semi-compliant balloon (p = 0.023). When plotted, the relationship pattern between volume and pressure fit a linear model for the compliant balloon, and a quadratic model for the semi-compliant balloon. Following attempted over inflation with the pressure valve, there was no change in parameters before and after attempted over inflation. CONCLUSIONS: The inflation profile differs between balloon designs. In contrast to semi-compliant balloons, compliant balloons will accommodate more volume to mitigate increase in pressure. This does not completely eliminate the risk of over inflation. The inflation characteristics of the semi-compliant balloon permit pairing it with a safety valve, which could lead to a development of a safer balloon technology in the future.

Safety and efficacy of radial access in trauma in 65 trauma endovascular cases.

OBJECTIVE: Endovascular techniques in trauma surgery are becoming increasingly important in patient management, with procedures such as pelvic and splenic angioembolization becoming the standard of care for certain injuries. Traditionally, such interventions are performed via femoral access, although the morbidity of this approach is not insignificant (3%-10%). Transradial access (TRA) is an attractive alternative, pioneered by cardiologists, with low rates of access site complications in patients undergoing coronary intervention. Recently, this technology has extended to other interventions. The aim of this study was to present the initial experience of a radial program in a busy trauma center, with specific regard to safety and complications. METHODS: The medical records of trauma patients undergoing endovascular procedures via TRA between March 2018 and December 2018 were queried for procedural and postoperative data. Demography and injury characteristics were presented for the overall cohort, followed by a comparison of procedural data and complications between laterality. Continuous variables were compared using a two-tailed t-test and categorical variables were compared using a χ2 test. RESULTS: Over a 9-month period, 65 patients underwent 81 interventions via TRA, most commonly solid organ or pelvic angiography/embolization. Radial artery access was achieved in all patients, with procedural success achieved in all but two patients (n = 63 [96.9%]) who had hypoplastic radial artery anatomy, who underwent ulnar access. The overall technique-related complication rate was 1.5% with no difference observed between laterality (n = 1; P = .523). One patient with an admission Glasgow Coma Score of 3 and coagulopathy developed radial artery thrombosis after pelvic angiography via right TRA. Mortality was seen in seven patients (10.8%) owing to hemorrhagic shock (n = 3 [42.8%]) or multiorgan failure (n = 4 [57.1%]). There were no cases of postprocedural access site bleeding, hematoma, pseudoaneurysm, vascular injury, intraoperative arrhythmia or cerebrovascular accident, arteriovenous fistula formation, or infection. CONCLUSIONS: TRA is a feasible and low-risk alternative for endovascular intervention in the trauma patient. It yields good technical success with low morbidity. Although larger studies are needed to establish the full efficacy of TRA at the multi-institutional level, this single-institution study demonstrates the legitimacy of an alternative means for endovascular intervention in the trauma patient.

A Comparison of Transradial and Transfemoral Access for Splenic Angio-Embolisation in Trauma: A Single Centre Experience.

OBJECTIVE: The study compared transradial access (TRA) and transfemoral access (TFA) for splenic angio-embolisation (SAE), with a focus on technical success, intra-operative adjuncts, and complications. METHODS: This was a retrospective comparative study of all trauma patients undergoing SAE by TRA or TFA between February 2015 and February 2019 at a single institution. The medical records were queried for procedural and post-operative data, with comparisons made based on access site. Continuous variables were compared using a two tailed t test and categorical variables were compared using a chi square test. RESULTS: Over a four year period, there were 47 cases of SAE via TRA and 127 via TFA. Technical success was 95.7% during TRA and 98.4% during TFA (p = .30). Technical failures were a result of failed splenic artery cannulation after successful radial or femoral access. Time to splenic cannulation was shorter in the TRA group (19 min vs. 30 min; p = .008). Two or fewer catheters were used during TRA, whereas more than two catheters were needed during TFA (p < .001). There were no statistically significant differences in procedure length, fluoroscopy time, radiation dose, or contrast volume between groups. Nine patients (5.2%) developed access related complications, all in the TFA group (p = .12). Mortality rate was 2.3% (n = 4), with no statistical significance between groups (p = .71). CONCLUSION: While TFA is the conventional strategy for SAE, TRA is a safe and efficacious modality for SAE in trauma patients. Although larger studies are needed to establish the full efficacy of TRA for SAE at the multi-institutional level, this single centre study demonstrates the legitimacy of an alternative means for SAE in the trauma population.