The evolution and development of a robotic acute care surgery program.

BACKGROUND: Acute care surgeons perform more than 850,000 operations annually on emergency general surgery patients in the United States. Emergency general surgery conditions are associated with a disproportionate excess of patient complications and death. Innovative quality improvement strategies have focused on addressing the excess morbidity and mortality among this patient population. Minimally invasive surgical techniques have been shown to reduce the burden experienced by emergency general surgery patients. Still, limited adoption by acute care surgeons has restricted this application's potential. An institutional robotics acute care surgery program provides acute care surgeons additional opportunities to expand minimally invasive surgery access to emergency general surgery patients irrespective of the time or day of the week. METHODS: A robotics acute care surgery program was developed and implemented at a high-volume academic institution within the division of trauma and acute care surgery. RESULTS: Three attending surgeons and two fellows within the trauma and acute care surgery division had successfully completed a defined robotics clinical pathway. As a result, around-the-clock use of a robotic surgical platform for emergency general surgery cases was implemented with routine use by trained robotic acute care surgeons and practicing fellows. CONCLUSION: The advancement of robotic surgical technology has opened new avenues for surgical application in the emergency setting. The development of a robotic acute care surgery program allows acute care surgeons to diversify their practice while providing greater access to minimally invasive approaches for emergency general surgery patients.

Rare Presentations of Rapidly Growing Liposarcomas.

Liposarcomas (LSs) are a rare form of malignant tumors. They are the most common primary neoplasms of the retroperitoneum. While these tumors rarely metastasise, they are characterised by local recurrence and infiltration. Moreover, most are asymptomatic and hence grow to massive sizes before becoming symptomatic. Here, we report two unique cases of giant retroperitoneal liposarcomas seen in our urban tertiary care centre. The first case is that of a 53-year Dominican male, who developed a massive recurrence of his retroperitoneal LS within a span of just two months after initial resection  ̶ an exceedingly rare occurrence. The second case is that of a 67-year Peruvian female, who was found to have a retroperitoneal LS, causing complete displacement of the viscera in her right hemiabdomen. Key Words: Liposarcomas, Recurrence, Retroperitoneum.

Jejunal Intussusception: A Rare Adult Presentation of Lymphoid Hyperplasia.

A 21-year-old African-American male presented to the emergency room with a sudden diffuse onset abdominal pain of one day duration. CT findings revealed mild telescoping of loops of small bowel and mesenteric fat in the left mid abdomen with no apparent masses. The patient underwent an exploratory laparoscopy revealing intussusception of the mid jejunum. As a fair amount of distention compromised safe navigation of the bowel, laparoscopic resection was not warranted at this time. Open approach allowed for segmental resection of the affected segment of the small bowel. This was followed by primary anastomosis. Pathological findings revealed focal reactive lymphoid hyperplasia with marked congestion in the lamina propria of the jejunum. The patient had an unremarkable postoperative period and recovered with no further complications.

H-2g, a glucose analog of blood group H antigen, mediates mononuclear cell recruitment via Src and phosphatidylinositol 3-kinase pathways.

OBJECTIVE: Monocyte recruitment by proinflammatory cytokines is a hallmark of rheumatoid arthritis (RA). Lewis(y-6) and H (Le(y)/H) are blood group antigens up-regulated on RA synovial endothelium. We have previously shown that both soluble Le(y)/H and a glucose analog of H, H-2g, are angiogenic and mediateleukocyte-endothelial adhesion via induction of intercellular adhesion molecule 1. We hypothesized that soluble Le(y)/H plays an important role in monocyte recruitment in RA. METHODS: We examined the role of H-2g in monocyte chemotaxis in vitro. We used an RA synovial tissue (ST)-SCID mouse chimera model to evaluate the role of H-2g in monocyte recruitment in vivo. We used Western blots to examine signaling molecules activated by H-2g in monocytes. RESULTS: H-2g induced human monocyte migration in vitro, which was mediated by Src and phosphatidylinositol 3-kinase (PI 3-kinase), since inhibitors and antisense oligodeoxynucleotides (ODNs) of Src and PI 3-kinase significantly decreased H-2g-induced monocyte migration (P < 0.05). H-2g significantly increased mononuclear cell (MNC) homing in vivo into an RA ST-SCID mouse chimera (P < 0.05). Transfection of MNCs with Src antisense ODNs blocked H-2g-induced MNC recruitment into the RA ST-SCID mouse chimera. Additionally, H-2g induced marked phosphorylation of protein kinase CalphaI/betaII (PKCalphaI/betaII), Src, IkappaBalpha, and Akt in monocytes. Src, Akt, and NF-kappaB were shown to be downstream targets of PKCalphaI/betaII, since an inhibitor of PKCalphaI/betaII reduced H-2g-mediated phosphorylation of Src, Akt, and NF-kappaB in monocytes. CONCLUSION: These data suggest that H-2g may be a novel mediator of monocyte recruitment in chronic inflammatory diseases like RA.