Risk Factors for Lower Extremity Minor Amputation Conversion to Major Amputation.

BACKGROUND: Minor lower extremity amputations (LEAs) have become an important part of the limb salvage approach but are not as benign as previously thought. This study investigates the difference in outcome between toe/ray versus midfoot amputations and the risk factors for major amputation conversion associated with each procedure. METHODS: We performed retrospective chart review of foot amputation patients at a single tertiary care medical center with a primary end point of conversion to major amputation and secondary end points of 1-year wound healing and mortality rate. We collected data on relevant medical comorbidities, noninvasive vascular imaging, revascularization, repeat amputations, wound healing rate, and 1-year mortality. Patients were separated into toe/ray amputations versus midfoot amputation groups and compared using descriptive statistics, Chi-squared tests, Cox proportional hazards, and a multivariate logistic regression model. RESULTS: A total of 375 amputations were included in the analysis. 65.3% (245 patients) included toe/ray amputations and 34.7% (130 patients) included midfoot amputations. We compared these 2 cohorts with regard to their rate of conversion to repeat minor and/or major amputation in addition to overall mortality. The toe/ray group underwent more repeat minor amputations within 1 year after index amputation (34.7% vs. 21.5%, P = 0.008) and wound healing (epithelization) at 90 days was also higher in this group. The midfoot group had a higher conversion to major LEA within 1 year on univariate analysis (20.8 vs. 6.9%, P < 0.001). Overall 1-year mortality was 6.17% and there was no significant difference between groups. CONCLUSIONS: While there is a consistency with previous studies that found no significant overall difference in mortality between types of minor LEA, we have extended this previous work by demonstrating the independent risk factors for conversion to major amputation between types of minor LEA. Comparing these 2 groups will assist surgeons in choosing the appropriate level of amputations and will enhance patient's understanding of their chance of wound healing and risk of repeat amputation.

Outcomes and Predictors of Morbidity after Carotid Body Tumor Resection.

BACKGROUND: Carotid body tumors (CBTs) are uncommon neuroendocrine tumors at the carotid bifurcation treated with resection. The goal of this study was to examine patient outcomes after CBT resection and establish predictors of morbidity. METHODS: Patients undergoing CBT resection were identified from the National Surgical Quality Improvement Program (NSQIP) database over 11 years. Demographics, past medical history, preoperative labs, procedural details, morbidity and mortality were recorded. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of morbidity. RESULTS: From 2010 to 2020, 668 CBT resections were identified. The majority of patients were female (65%) and White (72%) with a mean age of 56 (standard deviation [SD] ± 16). Average body mass index (BMI) was 29.9 (SD ± 7.1). Arterial resection occurred in 81 patients (12%). 6% of patients experienced morbidity, most commonly re-operation (2.4%). Morbidity was more common in patients with higher BMI (33.1 vs. 29.7, P = 0.005), chronic obstruction pulmonary disease (10% vs. 1.9%, P = 0.012), higher American Society of Anesthesiologists (P = 0.005), and lower albumin (3.7 vs. 4, P = 0.016). Morbidity was not increased with arterial resection (P = 1) or based on length of operation (P = 0.169). Morbidity did not impact mortality (P = 0.06) though led to longer length of stay [LOS] (8 days vs. 2.4, P < 0.001). On MLR, preoperative BMI was the only risk factor for morbidity (odds ratio 1.06, 95% confidence interval 1.02-1.1, P = 0.005). CONCLUSIONS: CBT resection is very well tolerated with low stroke rates, morbidity, and mortality. Arterial resection leads to increased transfusion requirements and LOS but did not increase stroke rates, mortality, or overall morbidity. Within the NSQIP database, preoperative BMI was the only predictor of postoperative morbidity, which leads to significantly longer LOS.

The Caged Knickerbocker: A Novel Modification to Targeted False Lumen Management in Complex Aortic Dissection.

INTRODUCTION: Targeted false lumen management has been described for complex presentations of aortic dissection. The "Knickerbocker" technique is often referenced and includes dilating a focal portion of an oversized endograft in the true lumen to purposefully rupture the false lumen septum, but at the expense of increased risk for visceral propagation and malperfusion. This case series describes a novel modification of the Knickerbocker technique by caging the distal end of the endograft prior to focal dilation. METHODS: A retrospective chart review was conducted at a tertiary academic center from 2018-2020. Patients were included if they had a history or current presentation of aortic dissection and underwent a Caged Knickerbocker (CKB) repair. Data were collected to include demographics, indications for repair, technical success, perioperative outcomes, hospital course, mortality, and further aortic interventions. RESULTS: Five patients were included in our evaluation. Four patients (80%) presented with chronic Type B aortic dissection (cTBAD) and concomitant aneurysmal degeneration of the thoracic aorta; 1 patient (20%) presented with an acute rupture secondary to cTBAD. Three patients (60%) had previous aortic repairs, 2 of which were for Type A Aortic Dissection that additionally required redo sternotomy and total arch replacement prior to CKB. CKB was technically successful in all cases with no peri-operative complications. Two (40%) patients required further aortic intervention due to aneurysmal degeneration. CONCLUSION: Achieving complete false lumen thrombosis is a considerable challenge when managing complex aortic dissections. Our data demonstrate the technical feasibly and early successful outcomes with the CKB approach. Importantly, CKB facilitates future distal extension into the para-visceral aorta in cases of complex thoracoabdominal aortic aneurysms. Further research should focus on discerning individual patients who will benefit from targeted false lumen management and compare outcomes between different approaches.

Open Proximal Endarterectomy with Retrograde Access and Stenting: A Novel Technique for Lower Extremity Revascularization.

BACKGROUND: Treatment of chronic limb threatening ischemia (CLTI) poses a significant clinical challenge despite recent medical advancements. Chronic total occlusion (CTO) lesions make endovascular approaches to CLTI particularly challenging. Open proximal exposure with retrograde access and stenting (OPERAS) aims to solve this challenge through retrograde subintimal crossing of a CTO with direct visualization of proximal re-entry into the true lumen. We describe this novel technique and present its efficacy in eight patients. METHODS: We conducted a retrospective case series at a single tertiary academic center. Data for patients who received OPERAS intervention included demographics, peri-operative details, and follow-up information. Statistical analysis was performed on length of stay, major post-operative complications, further intervention, clinical progression at 1 year, and amputation-free survival at 1 year. Immediate technical failure (ITF) and limb-based patency (LBP) at 1 year were calculated. RESULTS: Nine limbs underwent OPERAS between January 2019 and March 2020. Inflow was achieved with common femoral artery endarterectomy. All limbs underwent balloon angioplasty and stenting of the SFA, and seven underwent the same procedure in the popliteal artery. ITF was 0% for all nine cases. There were no major post-operative complications, and ankle-brachial index significantly improved pre-and post-operatively (P < .001). Eight limbs (88.9%) sustained amputation-free survival at 1 year, and overall LBP was 67% at 1 year. CONCLUSION: Our study presents a hybrid revascularization option to address severe, anatomically complex limbs (GLASS III) that lack a single autogenous conduit for open surgical revascularization. OPERAS addresses a main point of technical failure of subintimal techniques by directly visualizing the wire in the true lumen. Our data suggest that OPERAS can be effective to: (1) improve technical success of luminal re-entry following a subintimal approach; (2) address inflow concurrently with severe femoropopliteal disease; and (3) can be utilized when distal tissue loss is involved.

Robotic transanal minimally invasive surgery: a case series.

INTRODUCTION: This study describes the experience with robot-assisted transanal minimally invasive surgery (rTAMIS) at a single institution. TAMIS has become a popular minimally invasive technique for local excision of well-selected rectal lesions. rTAMIS has been proposed as another option as it improves the ergonomics of conventional laparoscopic techniques. METHODS: Retrospective case series of patients with rectal lesions who underwent rTAMIS. Patient demographics, final pathology, surgical and admission details, and clinical outcomes were recorded. Successful procedures were defined as having negative margins on final pathology. RESULTS: A total of 16 patients underwent rTAMIS by a single surgeon between April 2018 and December 2019. Mean age of patients was 63 years. Final pathologies were negative for tumor (n = 4), tubulovillous adenoma (n = 4), tubulovillous adenoma with high-grade dysplasia (n = 4), and invasive rectal adenocarcinoma (n = 4). 43% were located in the middle rectum and 56% were located in the distal rectum. Mean maximum diameter was 4.1 cm (IQR 2-3.1 cm). Negative margins were seen in 100% of the excision cases, and 100% were intact. Mean operative time was 87 min (IQR 54.8-97.3 min), and median length of stay was 0 days (IQR 0-1 days). Postoperative complications included incontinence (n = 1) and abscess formation (n = 2). rTAMIS provided curative treatment for 12/16 patients, and the remaining 4 patients received the appropriate standard of care for their respective pathologies. CONCLUSIONS: Robot-assisted TAMIS is a safe alternative to laparoscopic TAMIS for resection of appropriate rectal polyps and early rectal cancers. rTAMIS may provide a modality for resecting larger or more proximal rectal lesions due to the wristed instruments and superior visualization with the robotic camera. Future studies should focus on comparing outcomes between robotic and laparoscopic TAMIS, and whether rTAMIS allows for the removal of larger, more complex lesions, which may save patients from a more morbid radical proctectomy.

Trauma Service Utilization Increases Cost But Does Not Add Value for Minimally Injured Patients.

OBJECTIVE: Trauma care provides value to the critically injured. Our aim was to assess whether trauma team involvement adds value to the care of minimally injured patients and to define its costs. METHODS: Minimally injured patients admitted to a trauma center were propensity matched and compared by involvement versus no involvement of the trauma service (TS). Demographics, injury severity, complications, length of emergency department stay, mortality, and hospital costs and charges were studied. RESULTS: A total of 1253 patients were enrolled, with 308 propensity matched to the following groups: TS (n = 102) and no TS (n = 206). TS demonstrated a 30% increase in total charges and costs with no difference in complications. TS did demonstrate decreased time in the emergency department but had an increased delay to operation. Findings were similar when stratified for only lower extremity injuries. CONCLUSIONS: TS involvement for minimally injured patients does not increase value. Reducing TS involvement while avoiding trauma undertriage may reduce costs to the healthcare system without affecting outcomes.

Penetrating Injury to the Carotid Artery: Characterizing Presentation and Outcomes from the National Trauma Data Bank.

BACKGROUND: Penetrating injury to the neck can be devastating because of the multiple vital structures in close proximity. In the event of injury to the carotid artery, there is a significantly increased likelihood of morbidity or mortality. The purpose of this study was to assess presenting characteristics associated with penetrating injury to the carotid artery and directly compare approaches to surgical management. METHODS: Data from the National Trauma Data Bank from 2002-2016 were accessed to evaluate adult patients sustaining penetrating injury to the common or internal carotid artery. Management (operative versus nonoperative) and surgical approach (open versus endovascular) were evaluated based on presentation characteristics, and outcomes were compared after propensity score matching. RESULTS: Three thousand three hundred ninety-one patients fitting inclusion criteria and surviving past the emergency department were included in analyses (nonoperative: 1,976 [58.3%] patients and operative: 1,415 [41.7%] patients). The operative group was further classified by intervention as open = 1,192 patients and endovascular: 154 patients. On presentation, the nonoperative group demonstrated significantly higher prevalence of coma (Glasgow Coma Scale ≤8: nonoperative = 49.3% versus operative = 40.8%, P < 0.001), severe overall injury burden (Injury Severity Score ≥25: nonoperative = 42.3% versus operative = 33.3%, P < 0.001), and severe head injury (Abbreviated Injury Score ≥ 3: nonoperative = 44.9% versus operative = 22.0%, P < 0.001). After propensity score matching, the nonoperative group demonstrated higher mortality (nonoperative = 28.9% versus operative = 18.5%, P < 0.001), and lower rates of stroke (nonoperative = 6.6% versus operative - = 10.5%, P < 0.001). There were no differences in outcomes relating to surgical approach. CONCLUSIONS: These results indicate that nonoperative patients often present with a more severe overall injury burden, particularly injury to the head, and not surprisingly, have higher rates of mortality. The lack of significant differences in outcomes relating to surgical approach indicates open versus endovascular invention should be individualized to the patient-for example, based on presenting characteristics and the location of the injury.

Timing of intervention may influence outcomes in blunt injury to the carotid artery.

OBJECTIVE: Blunt carotid artery injury (BCI) is present in approximately 1.0% to 2.7% of all blunt trauma admissions and can result in significant morbidity and mortality. Management ranges from antithrombotic therapy alone to surgery, where potential indications include pseudoaneurysm, failed or contraindication to medical therapy, and progression of neurologic symptoms. Still, optimal management, including approach and timing, continues to be an active area for debate. The goal of this study was to assess the epidemiologic characteristics of BCI, and, after controlling for presenting features intrinsic to the data, compare outcomes based on management, operative approach, and timing of intervention. METHODS: A retrospective review was conducted of adult BCI patients identified within the National Trauma Data Bank from 2002 to 2016. The National Trauma Data Bank is the largest trauma database in the United States, collating data from each trauma admission for more than 900 trauma centers. Independent variables of interest included nonoperative versus operative management (OM); endovascular versus open intervention, and early (within 24 hours) versus delayed (after 24 hours) intervention. For each independent variable, groups were compared after propensity score matching to control for presenting factors and patterns of injury. RESULTS: There were 9190 patients who met the inclusion criteria, 812 of whom underwent operative intervention (open, n = 288; endovascular, n = 481, both: n = 43). During the review, there was no difference in proportion of OM over time, although there was a statistically significant decrease in the proportion of open intervention (0.48% per year; P < .05). For outcomes, operative versus nonoperative management (nOM) resulted in no difference in mortality, but the operative group demonstrated an increased risk of stroke (11.8% vs 6.5%), longer hospital and intensive care length of stay, and more days on mechanical ventilation (P < .001 for each). With regard to timing: mortality was increased for early intervention (early, 16% vs delayed, 6.3%; P < .001), which was predominantly driven by the endovascular cohort (early, 19.2% vs delayed, 2.5%; P < .001). CONCLUSIONS: In this study, there was no significant trend in the overall volume of operative or nOM; however, when considering approach to OM, there was a significant decrease in open procedures. Consistent with previous literature, injury to the neck, head, and chest was significant associated with BCI. Also outcomes demonstrated an increased prevalence of stroke after operative relative to nOM. Importantly, after critically assessing the timing to intervention, results strongly suggested that, if possible, intervention should be delayed for at least 24 hours.

Next Generation of Global Surgeons: Aligning Interest With Early Access to Global Surgery Education.

BACKGROUND: Although interest in global surgery is increasing among medical students,1 several questions remain unanswered such as: the association of demographics with said interest, the extent that global surgical burden education has been integrated into medical education, and the availability of global surgery electives. This study aimed to assess the current state of global surgery education in the United States (U.S.) to support recommendations for future curriculum development. MATERIALS AND METHODS: An anonymous online survey was distributed to medical students currently enrolled in the U.S. Descriptive data were compiled regarding interest in and access to global surgery programs; demographic data were analyzed using chi-squared testing for categorical variables. RESULTS: A total of 754 students from 18 medical schools throughout the U.S. responded to the survey. Only complete responses were included in final analysis (n = 658). Most of the respondents (66%) reported interest in global surgery, with a higher proportion of those interested being in their preclinical years. However, the majority (79%) reported that global surgery issues are rarely or never addressed in their required curriculum. Over half of respondents were unaware of whether their school even offers such programs. CONCLUSIONS: Although interest in global surgery is on the rise among medical students, results suggest that many currently lack exposure to global surgery concepts in their medical education. To that end, early exposure may be most effective during the preclinical years, so that the next generation may align global surgery participation with clinical aspirations, with the ultimate goal of addressing global disparities.

Using Expectancy Theory to quantitatively dissociate the neural representation of motivation from its influential factors in the human brain: An fMRI study.

Researchers have yet to apply a formal operationalized theory of motivation to neurobiology that would more accurately and precisely define neural activity underlying motivation. We overcome this challenge with the novel application of the Expectancy Theory of Motivation to human fMRI to identify brain activity that explicitly reflects motivation. Expectancy Theory quantitatively describes how individual constructs determine motivation by defining motivation force as the product of three variables: expectancy - belief that effort will better performance; instrumentality - belief that successful performance leads to particular outcome, and valence - outcome desirability. Here, we manipulated information conveyed by reward-predicting cues such that relative cue-evoked activity patterns could be statistically mapped to individual Expectancy Theory variables. The variable associated with activity in any voxel is only reported if it replicated between two groups of healthy participants. We found signals in midbrain, ventral striatum, sensorimotor cortex, and visual cortex that specifically map to motivation itself, rather than other factors. This is important because, for the first time, it empirically clarifies approach motivation neural signals during reward anticipation. It also highlights the effectiveness of the application of Expectancy Theory to neurobiology to more precisely and accurately probe motivation neural correlates than has been achievable previously.

Outcomes after Distal Pancreatectomy for Trauma in the Modern Era.

Multiple stump closure techniques after distal pancreatectomy (DP) for trauma have been described, and all are associated with a significant fistula rate. With increasing emphasis on abbreviated laparotomy, stapled pancreatectomy has become more common. This study describes the outcomes of patients with different closure techniques of the pancreatic stump after resection following pancreatic trauma. Retrospective analysis of 50 trauma patients, who sustained grade III pancreatic injuries with subsequent DP and stapled stump closure, were conducted from 1995 to 2011. Demographic, operative, and outcome data were analyzed to characterize patients, and to directly compare closure techniques. After 12 patients were excluded because of early death (<72 hours), final analyses included 38 patients: 19 (50%) had stapled closure alone and 19 (50%) had stapling with adjunct, including additional closure with sutures, fibrin sealants, or a combination of sutures with fibrin sealants/omental coverage. Twenty-four patients (63%) had postoperative complications, most commonly pancreatic fistula (n = 11, 29%). There were no significant differences with regard to pancreatic fistula or other abdominal complications between closure groups, or were any factors associated with increased likelihood of complications. DP remains a morbid operation after trauma regardless of closure technique. Stapled closure alone is perhaps the method of choice in this setting due to the time constraints directly related to outcomes.

Risk factors for perinatal mortality in patients admitted to the hospital with the diagnosis of placental abruption.

OBJECTIVE: Placental abruption is a clinical term used when premature separation of the placenta from the uterine wall occurs prior to delivery of the fetus. Hypertension, substance abuse, smoking, intrauterine infection and recent trauma are risk factors for placental abruption. In this study, we sought for clinical factors that increase the risk for perinatal mortality in patients admitted to the hospital with the clinical diagnosis of placental abruption. MATERIALS AND METHODS: We identified all placental abruption cases managed over the past 6 years at our Center. Those with singleton pregnancies and a diagnosis of abruption based on strict clinical criteria were selected. Eleven clinical variables that had potential for increasing the risk for perinatal mortality were selected, logistic regression analysis was used to identify variables associated with perinatal death. RESULTS: Sixty-one patients were included in the study with 16 ending in perinatal death (26.2%). Ethnicity, maternal age, gravidity, parity, use of tobacco, use of cocaine, hypertension, asthma, diabetes, hepatitis C, sickle cell disease and abnormalities of amniotic fluid volume were not the main factors for perinatal mortality. Gestational age at delivery, birthweight and history of recent trauma were significantly associated with perinatal mortality. The perinatal mortality rate was 42% in patients who delivered prior to 30 weeks of gestation compared to 15% in patients who delivered after 30 weeks of gestation (p < 0.05). A three-fold increase in severe trauma was reported in the group of patients with perinatal mortality than in the group with perinatal survivors (25% versus 7%, respectively, p < 0.05). CONCLUSIONS: In patients admitted to hospital for placental abruption delivery prior to 30 weeks of gestation and a history of abdominal trauma are independent risk factors for perinatal death.

Impact of procedure on the post-operative infection risk of patients after elective colon surgery.

BACKGROUND: Post-operative infection impacts the quality of patient care, prolongs the length of hospital stay, and utilizes more health care resources. The purpose of this study was to compare the rates of surgical site infection among three major surgical procedures for treating patients with colon pathology. HYPOTHESIS: The location of colon resection impacts the post-operative infection rate. METHODS: A retrospective cohort study was conducted by using the 2006 Nationwide Inpatient Sample. Adult patients (age ≥18 yr) with colon diseases are the population of interest. The disease status and procedures were categorized according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Patients with a primary diagnosis of diverticulosis of the colon without hemorrhage (ICD-9-CM codes: 562.11 and 562.12) or malignant neoplasm of the colon (ICD-9-CM codes: 153.x, where x represents the possible digits within this ICD-9-CM code category), with procedures of open and other right hemicolectomy (ORH; ICD-9-CM code: 45.73) or open and other left hemicolectomy (OLH; ICD-9-CM code: 45.75), or open and other sigmoidectomy (OS; ICD-9-CM code: 45.76) were included for this study. The primary measured outcome for the study was surgical site infection. RESULTS: There were an estimated 26,381 ORH procedures, 9,558 OLH procedures, and 31,656 OS procedures performed in 2006. There was a significant difference among procedures with respect to their age distributions (mean [standard error]: ORH vs. OLH vs. OS=70.5 [0.2] vs. 63.8 [0.3] vs. 59.5 [0.2] yr, p<0.0001) and the gender distributions (female percentage ORH vs. OLH vs. OS=56.1% vs. 51.5% vs. 50.9%, p<0.0001). There was a significant difference among the surgical procedures (infection rates: ORH vs. OLH vs. OS=2.9% vs. 5.6% vs. 4.9%, p<0.0001). From a logistic regression model, after controlling for age, gender, primary diagnosis, comorbidities, and hospital teaching status, OLH had a higher chance of SSI (adjusted odds ratio [AOR] [95% confidence interval {CI}]=1.54 [1.16-2,05], p=0.003) compared with ORH. However, OS did not have different SSI rates (AOR [95% CI]=1.18 [0.90-1.54], p=0.234) compared with ORH. There was a higher rate of infection for OLH (AOR [95% CI]: 1.31 [1.04-1.64], p=0.02) compared with OS. CONCLUSIONS: Different sites of colon operations were associated with different risks of surgical site infections. Accordingly, appropriate pre-operative measures should address these differences.

Decoding the neural representation of affective states.

Brain activity was monitored while participants viewed picture sets that reflected high or low levels of arousal and positive, neutral, or negative valence. Pictures within a set were presented rapidly in an incidental viewing task while fMRI data were collected. The primary purpose of the study was to determine if multi-voxel pattern analysis could be used within and between participants to predict valence, arousal and combined affective states elicited by pictures based on distributed patterns of whole brain activity. A secondary purpose was to determine if distributed patterns of whole brain activity can be used to derive a lower dimensional representation of affective states consistent with behavioral data. Results demonstrated above chance prediction of valence, arousal and affective states that was robust across a wide range of number of voxels used in prediction. Additionally, individual differences multidimensional scaling based on fMRI data clearly separated valence and arousal levels and was consistent with a circumplex model of affective states.

Neural representation of abstract and concrete concepts: a meta-analysis of neuroimaging studies.

A number of studies have investigated differences in neural correlates of abstract and concrete concepts with disagreement across results. A quantitative, coordinate-based meta-analysis combined data from 303 participants across 19 functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) studies to identify the differences in neural representation of abstract and concrete concepts. Studies that reported peak activations in standard space in contrast of abstract > concrete or concrete > abstract concepts at a whole brain level in healthy adults were included in this meta-analysis. Multilevel kernel density analysis (MKDA) was performed to identify the proportion of activated contrasts weighted by sample size and analysis type (fixed or random effects). Meta-analysis results indicated consistent and meaningful differences in neural representation for abstract and concrete concepts. Abstract concepts elicit greater activity in the inferior frontal gyrus and middle temporal gyrus compared to concrete concepts, while concrete concepts elicit greater activity in the posterior cingulate, precuneus, fusiform gyrus, and parahippocampal gyrus compared to abstract concepts. These results suggest greater engagement of the verbal system for processing of abstract concepts and greater engagement of the perceptual system for processing of concrete concepts, likely via mental imagery.