Perforated Peptic Ulcer of the Duodenum After the Laparoscopic Roux-en-Y Gastric Bypass.

Perforated ulcers of the gastric remnant and duodenum seem to be a rare complication after a Roux-en-Y gastric bypass. Diagnosis of this complication can be difficult given a vague presentation, however, early intervention is critical to prevent further morbidity. We present the case of a 38-year-old male with a perforated duodenal ulcer nearly a year after Roux-en-Y gastric bypass. Upon presentation, he complained of 8 hours of epigastric pain. His medical history was significant for chronic peptic ulcer disease and a negative history of H. pylori. Recently, he had been prescribed naproxen by his primary care physician for knee pain. His vital signs were normal with the exception of his systolic blood pressure which was 190 mmHg. He was diaphoretic and peritonitic on exam. He was taken emergently for a diagnostic laparoscopy and found to have a perforation of ∼5 mm of the anterior portion of his duodenum. This was repaired laparoscopically with an omental patch and the patient recovered without any further intervention required. While this is a rare complication reported in the literature, this or similar complications of the remnant stomach may be underrepresented in publications. The surgical intervention of this disease will either be resection of the remnant or an omental patch. However, controversy remains as to the proper post-operative medical treatment. For our patient, the inciting agent was likely the naproxen he was given and this was stopped immediately. Patient education and ownership should remain a cornerstone for patients that have undergone a Roux-en-y gastric bypass.

Appendectomy for Vague Symptoms and Equivocal Physical Findings on Physical Exam and Computed Tomography.

Background: Appendicitis is a common condition affecting 7-8% of the general population. With the improvement of noninvasive imaging, the diagnostic approach and treatment algorithm for patients with clear signs and symptoms suggestive of acute appendicitis are well agreed-upon. However, patients without pathognomonic signs and symptoms, but with equivocal imaging pose a diagnostic dilemma. These patients may still have acute appendicitis and could potentially benefit from laparoscopic appendectomy. This may be especially true in the subset of patients with appendicoliths.Methods: Our case series exams a group of patients with atypical symptoms who eventually underwent appendectomy and were followed after surgery for at least a month. This case series consists of eight patients with abdominal pain accompanied by a variety of other signs and symptoms in addition to laboratory results and imagining characteristics which were nondiagnostic. These patients had initial Alvarado scores ranging from 0-6.Results: All of these patients were subsequently taken to the operating room for diagnostic laparoscopy and laparoscopic appendectomy. Of these patients, six were known to have appendicoliths based on computed tomography obtained during initial diagnostic workup.Conclusions: All patients underwent a diagnostic laparoscopy and appendectomy. Four had appendicitis and four also had resolution of their symptoms. There exist atypical presentations of appendiceal disease. Patients with abdominal pain/tenderness, even without diagnostic laboratory results or imaging characteristics, may benefit from laparoscopic appendectomy.

Preperitoneal balloon tamponade and resuscitative endovascular balloon occlusion of the aorta: Alternatives to open packing for pelvic fracture-associated hemorrhage.

BACKGROUND: The objective of this study was to compare the efficacy of preperitoneal balloon tamponade (PPB), resuscitative endovascular balloon occlusion of the orta (REBOA), and open preperitoneal packing (OP) in a realistic animal model of pelvic fracture-associated hemorrhage. METHODS: Thirty-nine swine underwent creation of open-book pelvic fracture and iliac vascular injury. Animals were randomized to no intervention (n = 7), OP (n = 10), PPB (n = 9), zone 1 REBOA (n = 7), and zone 3 REBOA (n = 6) at a mean arterial pressure less than 40 mm Hg from uncontrolled hemorrhage. Primary outcome was survival at 1 hour. Secondary outcomes included survival in the immediate 10 m following intervention reversal, peak preperitoneal pressure (PP), blood loss, bleed rate, and peak lactate. RESULTS: Prior to injury, no difference was measured between groups for weight, hemodynamics, lactate, and hematocrit (all p = NS). The injury was uniformly lethal without intervention, with survival time (mean) of 5 m, peak PP of 14 mm Hg, blood loss of 960 g, bleed rate of 450 g/m, and peak lactate of 2.6 mmol/L. Survival time (m) was extended to 44 with OP, 60 with PPB, and 60 with REBOA (p < 0.01). Peak PP (mm Hg) was 19 with OP, 23 with PPB, 10 with zone 1 REBOA, and 6 with zone 3 REBOA (p < 0.05). Blood loss (g) was 850 with OP, 930 with PPB, 610 with zone 1 REBOA, and 370 with zone 3 REBOA (p < 0.01). Peak lactate (mmol/L) was 3.3 with OP, 4.3 with PPB, 13.4 with zone 1 REBOA, and 5.3 with zone 3 REBOA (p < 0.01). Only 33% of zone 1 REBOA animals survived the initial 10 m after balloon deflation, compared to 60% for OP, 67% for PPB, and 100% for zone 3 REBOA (p < 0.01). CONCLUSION: Preperitoneal balloon tamponade and zone 3 REBOA are effective alternatives to OP in this animal model of lethal pelvic fracture-associated hemorrhage. Zone 1 REBOA extends survival time but with high mortality upon reversal.

Minimally invasive preperitoneal balloon tamponade and abdominal aortic junctional tourniquet versus open packing for pelvic fracture-associated hemorrhage: Not all extrinsic compression is equal.

BACKGROUND: Minimally invasive preperitoneal balloon tamponade (PPB) and abdominal aortic junctional tourniquets (AAJT) have been proposed as alternatives to open preperitoneal packing (OP) for the management of pelvic fracture-associated hemorrhage. We hypothesized that the PPB (SpaceMaker Pro) and AAJT would result in similar rates of survival and blood loss versus OP. METHODS: Thirty-two swine underwent creation of a combined open-book pelvic fracture and major iliac vascular injuries. Animals were randomized to no intervention (n = 7), OP (n = 10), PPB (n = 9), or AAJT (n = 6) at a mean arterial pressure <40 mm Hg following initiation of uncontrolled hemorrhage. Survival (up to 60 minutes + 10 minutes after intervention reversal), hemodynamics, extraperitoneal pressures, blood loss, and associated complications were compared between groups. RESULTS: Prior to injury, no difference was measured between groups for weight, hemodynamics, lactate, and hematocrit (all p > 0.05). The injury was uniformly lethal without intervention, with survival time (mean) of 5 minutes, peak preperitoneal pressure (PP) of 14 mm Hg, blood loss of 960 g, and peak lactate of 2.6 mmol/L. Survival time was 44 minutes with OP versus 60 minutes with PPB and AAJT (p < 0.01). Peak PP (mm Hg) was 19 with OP, 23 with PPB, and 23 with AAJT (p > 0.05). Blood loss (g) was 850 with OP, 930 with PPB, and 600 with AAJT (p > 0.05). Peak lactate (mmol/L) was 3.3 with OP, 4.3 with PPB, and 6.3 with AAJT (p < 0.01). Only 33% of AAJT animals survived intervention reversal versus 60% for OP and 67% for PPB (p < 0.01). Necropsy revealed bowel/bladder injury in 50% of AAJT subjects versus 0% in all other arms (p < 0.01). CONCLUSION: Preperitoneal balloon tamponade is a safe and potentially effective alternative to OP for the management of lethal pelvic fracture-associated hemorrhage. Abdominal aortic junctional tourniquet offers a similar survival benefit to PPB but has concerning rates of ischemia-reperfusion and compressive abdominal organ injury.

Impact of a novel phosphoinositol-3 kinase inhibitor in preventing mitochondrial DNA damage and damage-associated molecular pattern accumulation: Results from the Biochronicity Project.

BACKGROUND: Despite improvements in the management of severely injured patients, development of multiple organ dysfunction syndrome (MODS) remains a morbid complication of traumatic shock. One of the key attributes of MODS is a profound bioenergetics crisis, for which the mediators and mechanisms are poorly understood. We hypothesized that metabolic uncoupling using an experimental phosphoinositol-3 kinase (PI3-K) inhibitor, LY294002 (LY), may prevent mitochondrial abnormalities that lead to the generation of mitochondrial DNA (mtDNA) damage and the release of mtDNA damage-associated molecular patterns (DAMPs). METHODS: Sixteen swine were studied using LY, a nonselective PI3-K inhibitor. Animals were assigned to trauma only (TO, n = 3), LY drug only (LYO, n = 3), and experimental (n = 10), trauma + drug (LY + T) groups. Both trauma groups underwent laparotomy, 35% hemorrhage, severe ischemia-reperfusion injury, and protocolized resuscitation. A battery of hemodynamic, laboratory, histological, and bioenergetics parameters were monitored. Mitochondrial DNA damage was determined in lung, liver, and kidney using Southern blot analyses, whereas plasma mtDNA DAMP analysis used polymerase chain reaction amplification of a 200-bp sequence of the mtDNA D-loop region. RESULTS: Relative to control animals, H + I/R (hemorrhage and ischemia/reperfusion) produced severe, time-dependent decrements in hepatic, renal, cardiovascular, and pulmonary function accompanied by severe acidosis and lactate accumulation indicative of bioenergetics insufficiency. The H-I/R animals displayed prominent oxidative mtDNA damage in all organs studied, with the most prominent damage in the liver. Mitochondrial DNA damage was accompanied by accumulation of mtDNA DAMPs in plasma. Pretreatment of H + I/R animals with LY resulted in profound metabolic suppression, with approximately 50% decreases in O2 consumption and CO2 production. In addition, it prevented organ and bioenergetics dysfunction and was associated with a significant decrease in plasma mtDNA DAMPs to the levels of control animals. CONCLUSIONS: These findings show that H + I/R injury in anesthetized swine is accompanied by MODS and by significant mitochondrial bioenergetics dysfunction, including oxidative mtDNA damage and accumulation in plasma of mtDNA DAMPs. Suppression of these changes with the PI3-K inhibitor LY indicates that pharmacologically induced metabolic uncoupling may comprise a new pharmacologic strategy to prevent mtDNA damage and DAMP release and prevent or treat trauma-related MODS. LEVEL OF EVIDENCE: Therapeutic study, level III.

There's an app for that: A handheld smartphone-based infrared imaging device to assess adequacy and level of aortic occlusion during REBOA.

BACKGROUND: Advances in thermal imaging devices have made them an appealing noninvasive point-of-care imaging adjunct in the trauma setting. We sought to assess whether a smartphone-based infrared imaging device (SBIR) could determine presence and location of aortic occlusion in a swine model. We hypothesized that various levels of aortic occlusion would transmit significantly different heat signatures at various anatomical points. METHODS: Six swine (35-50 kg) underwent sequential zone 1 (Z1) aortic cross clamping as well as zone 3 (Z3) aortic balloon occlusion (resuscitative endovascular balloon occlusion of the aorta [REBOA]). SBIR images and readings (FLIR One) were taken at five anatomic points (axilla [A], subcostal [S], umbilical [U], inguinal [I], medial malleolar [M]) and were used to determine significant thermal trends 5 minutes to 10 minutes after Z1 and Z3 occlusion. Significant (p ≤ 0.05) thermal ratio patterns were identified and compared among groups, and images were reviewed for obvious qualitative differences at the various levels of occlusion. RESULTS: Body temperatures were similar during control (CON), Z1 occlusion, and Z3 occlusion, ranging from 94.0 °F to 100.9 °F (p = 0.126). No significant temperature differences were found among A, S, U, I, M points prior to and after aortic occlusions. Among the anatomical 2-point ratios evaluated, A/M and S/M ratios were the best predictors of aortic occlusion, whether at Z1 (8.2 °F, p < 0.01; 10.9 °F, p < 0.01) or Z3 (7.3 °F, p < 0.01; 8.4 °F, p < 0.01), respectively. The best predictor of Z1 versus Z3 level of occlusion was the S/I ratio (5.2 °F, p < 0.05 vs. 3.4 °F, p = 0.27). SBIR generated qualitatively different thermal signatures among groups. CONCLUSION: SBIR was capable of detecting thermal trends during Z1 and Z3 aortic occlusion by using an anatomical 2-point thermal ratio. There were also easily recognized qualitative differences between control and occlusion images that would allow immediate determination of adequate occlusion of the aorta. SBIR represents a potential inexpensive and accurate tool for assessing perfusion, adequate REBOA placement, and even the aortic level of occlusion.

Preperitoneal balloon tamponade for lethal closed retroperitoneal pelvic hemorrhage in a swine model: A comparable and minimally invasive alternative to open pre-peritoneal pelvic packing.

BACKGROUND: The management of massive pelvic fracture-associated hemorrhage is extremely challenging, particularly in the unstable patient. We sought to characterize and compare the efficacy of a minimally invasive preperitoneal balloon technique (MIB) to standard open packing. METHODS: Twenty-six swine were randomized to control (C), open preperitoneal packing technique (OP), and MIB groups. A closed extraperitoneal iliac vascular injury followed by intervention + resuscitation over a 120-minute OP and MIB efficacy was assessed by procedure time, hemodynamics, extraperitoneal tamponade pressures (ETPs), blood loss, and survival. Angiography was performed in select animals, and ETPs were also measured in humans undergoing MIB placement for an elective procedure. RESULTS: Baseline parameters (mean arterial pressure [MAP] 29, 38, and 38 mm Hg; cardiac index [CI] 3.5, 3.8, and 4.2; and EPTs 5, 4, and 5 mm Hg) were similar among C, OP, and MIB groups, respectively (all p's > 0.05). The OP and MIB groups had markedly improved MAP and CI versus C. MIB generated significantly higher ETP (28 vs 17 mm Hg), was faster to deploy (164 vs 497 seconds), and had lower total blood loss versus OP (0.7 vs 1.2 L, all p's < 0.05). OP and MIB had equivalent survival times that were significantly improved versus C (91 and 116 vs 43 minutes, p < 0.05). Survival to 2 hours was 80% with OP versus 100% in the MIB group. Angiography showed no active extravasation in both study groups, but controlled partial deflation of the MIB allowed easy visualization of extravasation. Minimally invasive preperitoneal balloon inflation in five human subjects demonstrated a significant increase in mean ETP from 2.4 to 31 mm Hg (p < 0.01). CONCLUSION: Minimally invasive preperitoneal balloon tamponade was as effective as OP in improving hemodynamics and prolonging survival times, and performed superiorly to OP in time to placement, blood loss, and generation of tamponade pressures. The MIB allows for controlled deflation and reinflation to facilitate angiographic interventions, and may represent a promising new bedside intervention in this patient population.

Inducing metabolic suppression in severe hemorrhagic shock: Pilot study results from the Biochronicity Project.

BACKGROUND: Suspended animation-like states have been achieved in small animal models, but not in larger species. Inducing metabolic suppression and temporary oxygen independence could enhance survivability of massive injury. Based on prior analyses of key pathways, we hypothesized that phosphoinositol-3-kinase inhibition would produce metabolic suppression without worsening organ injury or systemic physiology. METHODS: Twenty swine were studied using LY294002 (LY), a nonselective phosphoinositol-3-kinase inhibitor. Animals were assigned to trauma only (TO, n = 3); dimethyl sulfoxide only (DMSO, n = 4), LY drug only (LYO, n = 3), and drug + trauma (LY + T, n = 10) groups. Both trauma groups underwent laparotomy, 35% hemorrhage, severe ischemia/reperfusion injury, and protocolized resuscitation. Laboratory, physiologic, cytokine, and metabolic cart data were obtained. Histology of key end organs was also compared. RESULTS: Baseline values were similar among the groups. Compared with the TO group, the LYO group had reversible decreases in heart rate, mean arterial pressure, cardiac output, oxygen consumption, and carbon dioxide production. Compared with TO, LY + T showed sustained decreases in heart rate (113 vs. 76, p = 0.03), mean arterial pressure (40 vs. 31 mm Hg, p = 0.02), and cardiac output (3.8 vs. 1.9 L/min, p = 0.05) at 6 hours. Metabolic parameters showed profound suppression in the LY + T group. Oxygen consumption in LY + T was lower than both TO (119 vs. 229 mL/min, p = 0.012) and LYO (119 vs. 225 mL/min, p = 0.014) at 6 hours. Similarly, carbon dioxide production was decreased at 6 hours in LY + T when compared with TO (114 vs. 191 mL/min, p = 0.043) and LYO (114 vs. 195 mL/min, p = 0.034) groups. There was no worsening of acidosis (lactate 6.4 vs. 8.3 mmol/L, p = 0.4) or other endpoints. Interleukin 6 (IL-6) showed a significant increase in LY + T when compared with TO at 6 hours (60.5 vs. 2.47, p = 0.043). Tumor necrosis factor α and IL-1ß were decreased, and IL-10 increased in TO and LY + T at 6 hours. Markers of liver and kidney injury were no different between TO and LY + T groups at 6 hours. CONCLUSIONS: Phosphoinositol-3-kinase inhibition produced metabolic suppression in healthy and injured swine without increasing end-organ injury or systemic physiologic markers and demonstrated prolonged efficacy in injured animals. Further study may lead to targeted therapies to prolong tolerance to hemorrhage and extend the "golden hour" for injured patients.

Efficacy of a novel fluoroscopy-free endovascular balloon device with pressure release capabilities in the setting of uncontrolled junctional hemorrhage.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an alternative to gauze packing (GP) in the setting of noncompressible torso hemorrhage. Our objective was to describe placement and physiologic impact of a novel REBOA device during uncontrolled junctional hemorrhage. We hypothesized that REBOA could be deployed without fluoroscopic guidance or intra-aortic barotrauma and could increase survival in the setting of profound shock physiology. METHODS: Fourteen adult swine (35-50 kg) underwent a hemorrhage and ischemia/reperfusion injury protocol to produce shock physiology and dilutional coagulopathy and randomized to REBOA (n = 8) or standard GP (n = 6) groups. A complex contralateral groin soft tissue and vascular injury was then created, followed by 30 seconds of free bleeding and GP for 5 minutes. The REBOA group had the aortic balloon inflated in aortic Zone III until the pressure release valve opened, followed by 45-minute postpacking survival, after which native and balloon-exposed aortae were harvested for histologic analysis. RESULTS: Control and REBOA groups had similar baseline hemodynamics (mean arterial pressure, 32 mm Hg vs. 43 mm Hg; p = 0.228), levels of coagulopathy (international normalized ratio, 1.3 vs. 1.2, p = 0.476; fibrinogen, 108 vs. 135 mg/dL, p = 0.747), and hemorrhage/ischemia/reperfusion insult (lactate, 7 vs. 7, p = 0.950; base deficit, 9 vs. 5, p = 0.491). No histologic barotrauma was identified, and 88% of the REBOA devices were successfully deployed into the Zone III of the aorta. The REBOA group had significantly decreased hemorrhage volumes (0.5 L vs. 0.2 L, p = 0.014) and increased survival times (45 minutes vs. 8 minutes, p < 0.001). CONCLUSION: This study reinforces results found in previous studies that REBOA is an effective method to increase survival in the setting of noncompressible torso hemorrhage and is the first to show that this specific REBOA device can be blindly guided into the appropriate zone of the aorta without generating aortic wall injury during unmeasured balloon inflation.

Prehospital interventions in severely injured pediatric patients: Rethinking the ABCs.

BACKGROUND: The current conflict in Afghanistan has resulted in a high volume of significantly injured pediatric patients. The austere environment has demanded emphasis on prehospital interventions (PHIs) to sustain casualties during transport. METHODS: The Department of Defense Trauma Registry was queried for all pediatric patients (≤18 years) treated at Camp Bastion from 2004 to 2012. PHIs were grouped by Advanced Trauma Life Support categories into (1) airway (A)--intubation or surgical airway; 2) breathing (B)--chest tube or needle thoracostomy; and 3) circulation (C)--tourniquet or hemostatic dressing. Outcomes were assessed based on injury severity, hemodynamics, blood products and fluids, as well as mortality rates. RESULTS: There were 766 injured children identified with 20% requiring one or more PHIs, most commonly circulation (C, 51%) followed by airway (A, 40%) and breathing (B, 8.7%). The majority of C interventions were tourniquets (85%) and hemostatic dressings (15%). Only 38% of patients with extremity vascular injury or amputation received a C intervention, with a significant reduction in blood products and intravenous fluids associated with receiving a C PHI (both p < 0.05). A interventions consisted of endotracheal intubation for depressed mental status (Glasgow Coma Scale [GCS] score < 8). Among patients with traumatic brain injury, A interventions were associated with higher unadjusted mortality (56% vs. 20%, p < 0.01) and remained independently associated with increased mortality after multivariate adjustment (odds ratio, 5.9; p = 0.001). B interventions were uncommon and performed in only 2% of patients with no recorded adverse outcomes. CONCLUSION: There is a high incidence of PHIs among pediatric patients with severe wartime injuries. The most common and effective were C PHI for hemorrhage control, which should remain a primary focus of equipment and training. A interventions were most commonly performed in the setting of severe traumatic brain injury but were associated with worse outcomes. B interventions seem safe and effective and may be underused. LEVEL OF EVIDENCE: Care management/therapeutic study, level IV.

Use of resuscitative endovascular balloon occlusion of the aorta in a highly lethal model of noncompressible torso hemorrhage.

Noncompressible torso hemorrhage is a leading cause of death in trauma, with many patients dying before definitive hemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct than can be used to expand the window of salvage in patients with end-stage hemorrhagic shock. The aim of this study was to evaluate the effect of continuous and intermittent REBOA (iREBOA) on mortality using a highly lethal porcine model of noncompressible torso hemorrhage. Male splenectomized pigs (70-90 kg) underwent a laparoscopic liver injury (80% resection of left lobe) followed by a 10-min free-bleed period. Animals were then divided into three groups (n = 8) for a 60-min intervention phase (n = 8): continuous occlusion (cREBOA), iREBOA, or no occlusion (nREBOA). Groups then underwent whole blood resuscitation, damage control surgery, and further critical care. Endpoints were mortality and hemodynamic and circulating measures of shock and resuscitation. Systolic blood pressure (in mmHg) at the end of the free-bleed period for cREBOA, iREBOA, and nREBOA was 31 ± 14, 48 ± 28, and 28 ± 17, respectively (P = 0.125). Following the start of the intervention phase, systolic blood pressure was higher in the iREBOA and cREBOA groups compared with the nREBOA (85 ± 37 and 96 ± 20 vs. 42 ± 4; P < 0.001). Overall mortality for the cREBOA, iREBOA, and nREBOA groups was 25.0%, 37.5%, and 100.0% (P = 0.001). Resuscitative endovascular balloon occlusion of the aorta can temporize exsanguinating hemorrhage and restore life-sustaining perfusion, bridging critical physiology to definitive hemorrhage control. Prospective observational studies of REBOA as a hemorrhage control adjunct should be undertaken in appropriate groups of human trauma patients.