Time to weigh in on obesity and associated comorbidities in combat-wounded amputees.

BACKGROUND: The Joint Trauma System database estimates that about 1,200 individuals have sustained a combat-related amputation during the Global War on Terror. Previous retrospective studies have demonstrated that combat-related amputees develop obesity and cardiovascular disease, but the incidence of obesity and associated comorbidities in this population is unknown. The objectives of this study are to determine the prevalence of obesity in the military amputee population and to compare this with the general population. METHODS: This is a retrospective review of 978 patients who sustained a combat-related amputation from 2003 to 2014. Prevalence of obesity and comorbid conditions were determined. A multivariate logistic regression model was performed to identify risk factors for postamputation obesity. Kaplan-Meier curves were constructed using obesity as the event of interest. RESULTS: A total of 1,233 charts were reviewed with 978 patients included for analysis. The median age of injury was 24 years. Median follow-up time was 8.7 years, ranging from 0.5 years to 16.9 years. The average Injury Severity Score was 23.3. The average body mass index preinjury was 25.6 kg/m2, and the average most recent corrected body mass index was found to be 31.4 kg/m2. Prevalence of comorbidities was higher in the amputee population. Fifty percent of patients who progressed to obesity did so within 1.3 years. CONCLUSION: There is a notable prevalence of obesity that develops in the amputee population that is much higher than the general population. We determined that the amputee population is at risk, and these patients should be closely monitored for 1 to 2.5 years following injury. This study provides a targeted period for which monitoring and intervention can be implemented. LEVEL OF EVIDENCE: Retrospective, basic science, outcomes analysis, level III/IV.

Fatty-falciform ligament appendage torsion (F-FLAT): Diagnosis and management in a pediatric patient.

Fatty-falciform ligament appendage torsion (F-FLAT) is a rare condition manifested by torsion of the extraperiotoneal fat within the falciform ligament. It is similar to intraperitoneal focal fatty infarctions, including omental infarction and epiploic appendagitis. We report herein the first case of F-FLAT in a pediatric patient that failed conservative management. Ultrasound and CT scan facilitated prompt diagnosis of this rare finding and expedited a quick trial of conservative management. Despite conservative treatment, symptoms persisted for 4 weeks, but resolved after laparoscopic single-site surgical resection. In this report, we discuss the clinical features, key radiographic findings, and treatment options for this unique condition. This is only the third reported pediatric case of F-FLAT in the literature, and the first pediatric case to require surgical resection.

Litigation Patterns in Inguinal Hernia Surgery: A 25 Year Review.

BACKGROUND: Inguinal herniorraphyis among the most common procedures performed by general surgeons, but risk factors for litigation related to this surgery are poorly defined. METHODS: Cases were retrieved by searching the Westlaw database from 1991 through 2016 using the search terms "inguinal hernia" OR "inguinal herniorrhaphy" OR "inguinal hernioplasty" and "medical malpractice." Data were compiled on the demographics of the patient, operative case details, nature of injury, legal allegations, verdicts, and indemnities. RESULTS: Forty-six cases met inclusion criteria and were selected for review. Verdicts for the defendant predominated (67%). The average plaintiff's monetary award for a plaintiff verdict or settlement was $1.21 million (median $500,000). The most frequent legal argument was improper performance (n = 35, 76%), followed by failure of informed consent (n = 14, 30%). The most common complications were nerve/chronic pain (n = 20, 45%) and testicular damage (n = 10, 23%). No association was discovered between case outcome and patient gender (P = 0.231) or age (P = 0.899). Case outcome was not different between open and laparoscopic repairs (P = 0.722). Patient mortality was not associated with case outcome (P = 0.311). There was no chronological trend in case outcome or award amount. Settlement award amounts were not significantly different than plaintiff awards (P = 0.390). CONCLUSIONS: Successful litigation after inguinal hernia surgery was relatively infrequent-only 21.7%-with an additional 10.9% resulting in settlement awards. Case outcome in litigation for hernia surgery was not predicted by patient demographics, type of procedure, or type of complication in this data set.

The safe use of surgical energy devices by surgeons may be overestimated.

BACKGROUND: Surgical energy injuries are an underappreciated phenomenon. Improper use of surgical energy or poor attention to patient safety can result in operating room fires, tissue injuries, and interferences with other electronic devices, while rare complications can be devastatingly severe. Despite this, there is no current standard requirement for educating surgeons on the safe use of energy-based devices or evaluation of electrosurgery (ES) education in residency training, credentialing, or practice. The study aimed to assess the current baseline knowledge of surgeons and surgical trainees with regards to ES across varying experiences at a tertiary level care center. METHODS: Surgeons and surgical trainees from seven surgical specialties (General Surgery, Cardiothoracic Surgery, Vascular Surgery, Obstetrics/Gynecology, Orthopedic Surgery, Urology, and Otorhinolaryngology) at a tertiary level care hospital were tested. Testing included an evaluation regarding their background training and experiences with ES-related adverse events and a 15 multiple-choice-question exam testing critical knowledge of ES. RESULTS: A total of 134 surveys were sent out with 72 responses (53.7%). The mean quiz score was 51.5 ± 15.5% (passing score was 80%). Of staff surgeons, 33/65 (50.8%) completed the survey with mean and median scores of 54.9 and 53.3%, respectively (range 33.3-86.7%). Of surgical trainees, 39/69 (56.5%) completed the survey with mean and median scores of 48.6 and 46.7%, respectively (range 13.3-80.0%). There were no statistically significant differences based on training status (p = 0.08), previous training (p = 0.24), number of cases (p = 0.06), or specialty (p = 0.689). CONCLUSION: Surgeons and surgical trainees both have a significant knowledge gap in the safe and effective use of surgical energy devices, regardless of surgical specialty and despite what they feel was adequate training. The knowledge gap is not improved with experience. A formal surgical energy education program should be a requirement for residency training or credentialing.

Evaluation of a Novel Hybrid Viable Bioprosthetic Mesh in a Model of Mesh Infection.

BACKGROUND: The reported incidence of mesh infection in contaminated operative fields is as high as 30% regardless of material used. Our laboratory previously showed that augmenting acellular bioprosthetic mesh with allogeneic mesenchymal stem cells (MSC) enhances resistance to bacterial colonization in vivo and preserves mesh integrity. This study's aim was to determine whether augmentation of non-crosslinked porcine dermis (Strattice) with commercially available, cryopreserved, viable MSC-containing human placental tissue (Stravix) similarly improves infection resistance after inoculation with Escherichia coli (E. coli) using an established mesh infection model. METHODS: Stravix was thawed per manufacturer's instructions and 2 samples were tested for cell viability using a Live/Dead Cell assay at the time of surgery. Rats (N = 20) were implanted subcutaneously with 1 piece of Strattice and 1 piece of hybrid mesh (Strattice + Stravix sutured at the corners). Rats were inoculated with either sterile saline or 106 colony-forming units of E. coli before wound closure (n = 10 per group). At 4 weeks, explants underwent microbiologic and histologic analyses. RESULTS: In E. coli-inoculated animals, severe or complete mesh degradation concurrent with abscess formation was observed in 100% (10/10) hybrid meshes and 90% (9/10) Strattice meshes. Histologic evaluation determined that meshes inoculated with E. coli exhibited severe acute inflammation, which correlated with bacterial recovery (P < 0.001). Viability assays performed at the time of surgery failed to verify the presence of numerous live cells in Stravix. CONCLUSIONS: Stravix cryopreserved MSC-containing human umbilical tissue does not improve infection resistance of a bioprosthetic mesh in vivo in rats after inoculation with E. coli.

An unusual presentation of a rare disease: posterior reversible encephalopathy syndrome following abdominal sepsis.

Posterior reversible encephalopathy syndrome (PRES) is an unusual disease of unknown incidence and cause. There are a wide range of associated, predisposing medical causes to include pregnancy, renal failure, immunosuppressive medication administration and hypertension. The diagnosis is made following the radiographic identification of characteristic vasogenic edema in the setting of neurologic impairment. A significant portion of patients will have long-term, if not permanent, sequelae of the disease. We present a patient who developed PRES following a hemicolectomy that was complicated by an anastomotic leak. She went on to a complete recovery following surgical treatment of the leak and supportive care.

Primary aortoduodenal fistula: a rare entity with lethal effects.

Primary aortoduodenal fistula (ADF) is a rare but morbid diagnosis. Here, we present the case of a patient with a primary ADF that resulted in mortality. Despite multiple attempts at radiographic and endoscopic diagnosis, the fistula did not declare itself until the patient exsanguinated. Given the morbidity associated with ADF and the imperfection of associated diagnostic studies, a high index of suspicion is required to make a timely diagnosis.

Bone Marrow-Derived Mesenchymal Stem Cells Enhance Bacterial Clearance and Preserve Bioprosthetic Integrity in a Model of Mesh Infection.

BACKGROUND: The reported incidence of mesh infection in contaminated operative fields is as high as 30% regardless of the material used. Recently, mesenchymal stem cells (MSCs) have been shown to possess favorable immunomodulatory properties and improve tissue incorporation when seeded onto bioprosthetics. The aim of this study was to evaluate whether seeding noncrosslinked bovine pericardium (Veritas Collagen Matrix) with allogeneic bone marrow-derived MSCs improves infection resistance in vivo after inoculation with Escherichia coli (E. coli). METHODS: Rat bone marrow-derived MSCs at passage 3 were seeded onto bovine pericardium and cultured for 7 days before implantation. Additional rats (n = 24) were implanted subcutaneously with MSC-seeded or unseeded mesh and inoculated with 7 × 10(5) colony-forming units of E. coli or saline before wound closure (group 1, unseeded mesh/saline; group 2, unseeded mesh/E. coli; group 3, MSC-seeded mesh/E. coli; 8 rats per group). Meshes were explanted at 4 weeks and underwent microbiologic and histologic analyses. RESULTS: MSC-seeded meshes inoculated with E. coli demonstrated superior bacterial clearance and preservation of mesh integrity compared with E. coli-inoculated unseeded meshes (87.5% versus 0% clearance; p = 0.001). Complete mesh degradation concurrent with abscess formation was observed in 100% of rats in the unseeded/E. coli group, which is in contrast to 12.5% of rats in the MSC-seeded/E. coli group. Histologic evaluation determined that remodeling characteristics of E. coli-inoculated MSC-seeded meshes were similar to those of uninfected meshes 4 weeks after implantation. CONCLUSIONS: Augmenting a bioprosthetic material with stem cells seems to markedly enhance resistance to bacterial infection in vivo and preserve mesh integrity.