A Peculiar Case of Small Bowel Stricture in a Coronavirus Disease 2019 Patient with Congenital Adhesion Band and Superior Mesenteric Vein Thrombosis.

BACKGROUND: There is increasing evidence supporting coronavirus disease 2019 (COVID-19)-related coagulopathy. In the available literature, only 2 cases of superior mesenteric vein thrombosis have been described. METHODS: We present a peculiar case of high-grade small bowel obstruction in a patient with COVID-19 infection. RESULTS: Exploratory laparotomy revealed a congenital adhesion band with associated focal bowel ischemia contributed by superior mesenteric vein thrombosis and positive lupus anticoagulant. CONCLUSIONS: It is important to consider the rare differential of mesenteric vein thrombosis and its related sequelae of mesenteric ischemia in a patient with COVID-19 who presents with abdominal pain.

Improving postoperative mobilisation rates in patients undergoing elective major hepatopancreatobiliary surgery.

BACKGROUND: Early mobilisation reduces postoperative complications such as pneumonia, deep vein thrombosis and hospital length of stay. Many authors have reported poor compliance with early mobilisation within Enhanced Recovery After Surgery initiatives. OBJECTIVES: The primary objective was to increase postoperative day (POD) 2 mobilisation rate from 23% to 75% in patients undergoing elective major hepatopancreatobiliary (HPB) surgery within 6 months. METHODS: We report a multidisciplinary team clinical practice improvement project (CPIP) to improve postoperative mobilisation of patients undergoing elective major HPB surgery. We identified the common barriers to mobilisation and analysed using the fishbone or cause-and-effect diagram and Pareto chart. A series of Plan-Do-Study-Act cycles followed this. We tracked the rate of early mobilisation and mean distance walked. In the post hoc analysis, we examined the potential cost savings based on reduced hospital length of stay. RESULTS: Mobilisation rate on POD 2 following elective major HPB surgery improved from 23% to 78.9%, and this sustained at 6 months after the CPIP. Wound pain was the most common reason for failure to ambulate on POD 2. Hospital length of stay reduced from a median of 8 days to 6 days with an estimated cost saving of S$2228 per hospital stay. CONCLUSION: Multidisciplinary quality improvement intervention effort resulted in an improved POD 2 mobilisation rate for patients who underwent elective major HPB surgery. This observed outcome was sustained at 6 months after completion of the CPIP with potential cost savings.

Effect of Thoracic Endovascular Aortic Repair on Aortic Remodeling in Patients with Type B Aortic Dissection in an Asian Population.

BACKGROUND: Management of uncomplicated type B aortic dissection (TBAD) has traditionally been aggressive medical therapy. Recent studies brought about a paradigm shift with evidence to suggest benefits from early endovascular intervention to a high risk subgroup of acute uncomplicated TBAD patients. AIMS: We aim to review the effects of aortic remodeling in Asian patients with TBAD with and without endovascular intervention, including maximal aortic diameter, true lumen diameter, and false lumen thrombosis. METHODS: This is a single-center retrospective study of a prospective database. Patients who presented to our institution with acute TBAD from January 2008 to December 2015 (n = 44) were evaluated. Eighteen percent (8 patients) presented with complicated TBAD and underwent emergency thoracic endovascular aortic repair (TEVAR) while the remaining 82% (36 patients) were treated with optimal medical therapy (OMT). RESULTS: Six patients under the conservative arm crossed over to elective TEVAR after 6 weeks because of interval radiological progression of disease. There was no significant difference in the baseline demographics of the TEVAR group and the OMT group. At 24 months, mean maximal aortic diameter difference was -7.7 mm and +1.9 mm (P = 0.077), mean true lumen diameter difference was +10.0 mm and +2.6 mm (P = 0.049), and false lumen thrombosis was 100% and 20% (P = 0.012) for TEVAR and OMT, respectively. Kaplan-Meier analysis showed no significant difference in mortality between the 2 groups at 30 days and 2 years. CONCLUSIONS: Within an Asian population with TBAD, TEVAR with OMT has a significant positive effect on aortic remodeling, compared with OMT-only management.

Postoperative spinal epidural hematoma following therapeutic anticoagulation: case report and review of literature.

While the incidence and risk factors of pulmonary embolism (PE) and deep vein thrombosis (DVT) following spinal surgery have been well studied, the treatment of such thromboembolic disease in patients after spine surgery remains controversial. When initiating therapeutic anticoagulation after spine surgery, clinicians must weigh the catastrophic risk of a PE against the risk of bleeding complications associated with anticoagulation therapy. Here we report the case of a 56-year-old male who presented with symptoms of spinal cord compression secondary to metastatic renal cell carcinoma (RCC). An inferior vena cava (IVC) filter was inserted preoperatively and urgent decompression at the thoraco-lumbar region was performed. Therapeutic clexane was started on postoperative day (POD) 7 and he was discharged. On POD 8, he was readmitted following acute bilateral lower limb paralysis. Magnetic resonance imaging (MRI) revealed a large posterior spinal epidural hematoma with severe compression of the conus at L1 level. Urgent posterior decompression was performed but subsequent recovery was slow and incomplete. His power improved gradually over the right lower limb with attainment of grade 4/5 motor power but still had hemiparesis on his left lower limb upon discharge out of hospital. This case highlights the risk of starting therapeutic anticoagulation following spinal surgery. Prior to starting treatment, the clinician must consider the appropriate dose, timing and alternatives available to avoid unnecessary complications.