Endometriosis of the Appendix: When Appendicitis Is Less Than Straightforward.

We present a case report of a 49-year-old female with a history of ulcerative colitis who originally presented to the general surgery clinic after an incidental finding on computed tomography was concerning for a dilated, fluid-filled appendix. She ultimately underwent a laparoscopic appendectomy. The pathology returned consistent with early acute appendicitis, with endometrial tissue along the outer wall of the appendix. We then performed a literature review regarding appendiceal masses and the occurrence of endometriomas and/or endometriosis of the appendix. A PubMed search was performed using the key words of appendix and appendicitis and endometrioma. Specific articles were examined mentioning the occurrence of endometriomas of the appendix and isolated endometriosis of the appendix. Between 2% and 6% of cases of appendicitis present due to an appendiceal mass, usually an inflammatory phlegmon. A variety of other causes, including primary malignancy, secondary malignancy, and combinations of pathologies, may lead to the eventual removal of the appendix. Specifically, endometriosis of the appendix is reported in less than 1% of females on post-appendectomy pathologic analysis. Although specific symptoms may guide a provider, there are few distinguishing symptoms that would point a provider toward a different etiology, to include malignancy, for appendicitis. Further information is needed to determine when a patient has an increased risk for an underlying pathology when presenting with appendicitis. This information will help drive continued treatment and lead to improved screening for appendiceal masses.

Proton Pump Inhibitors, Associated Complications, and Alternative Therapies: A Shifting Risk Benefit Ratio.

OBJECTIVE: Our goal was to compile the most recent and accurate data on the side effects of proton pump inhibitors (PPI). We also compared the efficacy of PPI to the efficacy of different surgical options for acid reflux control. BACKGROUND: Proton pump inhibitors are the primary therapy for chronic control of gastroesophageal reflux disease (GERD), but newer studies demonstrate deleterious side effects. Collating this information and contrasting it with surgical therapy for GERD provides evidence for possible practice changes in treatment. METHODS: A literature search utilizing PubMed was performed evaluating for PPI and anti-reflux surgery (ARS), focusing on articles that reflected information regarding the usage and efficacy of symptom control of both PPI and ARS. Search terms included "ARS, fundoplication, MSA, acute interstitial nephritis, acute kidney injury, chronic kidney disease, meta-analysis, PPI, H2 blocker, cardiovascular risk, and gut dysbiosis." We evaluated 271 articles by title, abstract, and data for relevance and included 70. RESULTS: Long-term control of GERD with PPI may have a greater than expected side effect profile than initially thought. Surgical options may provide greater symptom control than PPI without the side effects of long-term medical therapy. CONCLUSIONS: Anti-reflux control can be safely achieved with either PPI or surgical options; however, the long-term side effects noted in the review such as increased risk of cardiovascular events, renal disease, and gut dysbiosis may suggest surgical anti-reflux control as a better long-term option.

Conducting Pre-deployment Training in Honduras: The 240th Forward Resuscitative Surgical Team Experience.

INTRODUCTION: Since January 2002, pre-deployment training of forward resuscitative and surgical units has taken place at the U.S. Army Trauma Training Center (ATTC) in Miami, FL. In June 2019, the 240th Forward Resuscitative Surgical Team (FRST) conducted the first pre-deployment Surgical Readiness Training Exercise (SURGRETE) in San Pedro Sula, Honduras, to allow the team to rehearse in a resource-constrained environment more similar to that expected on deployment. The purpose of this study is to describe and compare the pre-deployment training experiences of the 240th FRST during their SURGRETE in Honduras and ATTC rotation in Miami, FL. MATERIALS AND METHODS: A descriptive analysis of prospectively collected data was performed for surgical cases, trauma resuscitations, and nonsurgical procedures by the 240th FRST over a 2-week SURGRETE in Honduras and 2-week ATTC rotation in Miami, FL. Items accomplished within the Individual Critical Task Lists (ICTLs) of key clinical providers on the team (general surgeon, orthopedic surgeon, emergency medicine physician, and Certified Registered Nurse Anesthetist) were identified and compared to those accomplished at the ATTC. RESULTS: During the SURGRETE in Honduras, 64 surgical cases, 1 trauma resuscitation, 2 Advanced Cardiac Life Support codes, and 213 nonsurgical procedures were performed collectively by the team. During ATTC rotation, the team performed a combined total of 10 surgical cases, 6 trauma resuscitations, and 56 nonsurgical procedures. For each key clinical provider, more of their assigned ICTLs were conducted during the Honduras SURGRETE than during ATTC rotation. The ATTC, however, offered more cases of acute life-threatening trauma. CONCLUSION: Appropriately planned SURGRETEs can provide a concentrated case volume in a resource-constrained setting and challenge the team to consider definitive management algorithms. The cases performed may not necessarily reflect the type and acuity of operations performed in a deployed environment; however, they facilitate repetition of basic skills, team cohesion, and cross-training. The SURGRETE experience could be improved by locating a facility with a trauma-dominant patient population that allows increased autonomy of U.S. physicians.

Biloma Secondary to Percutaneous Liver Biopsy Case Report.

Biloma and biliary leak after percutaneous liver biopsy (PLB) are rare. Previous cases are largely in the setting of transplant, oncology, and cirrhotic patients. Patients can be asymptomatic, peritoneal, or present with obstructive symptoms, including bilirubinemia. A 55-year-old male referred for transaminitis attributed to nonalcoholic fatty liver disease (NAFLD) underwent an ultrasound- (US-) guided PLB. He returned the same day with abdominal pain, normal vitals, a nontender abdomen, and a leukocytosis. He was found to have a subcapsular fluid collection attributed to a hematoma. He underwent observation and was discharged. He presented 4 days later with fever, tachycardia, leukocytosis, and bilirubinemia. CT demonstrated growth of the subcapsular fluid collection. Percutaneous drainage revealed bilious fluid. He was transferred for endoscopic retrograde cholangiopancreatography (ERCP). A right biliary branch was stented, and he was discharged the following day with antibiotics. US should be utilized for percutaneous biopsies to avoid biliary complications. Typical presentations of biliary complications include abdominal pain and biliary obstruction. The differential diagnosis for perihepatic and subcapsular fluid collections after PLB should include bile. ERCP should be offered for the treatment of larger or symptomatic collections.

Characteristics of Iraqi Patients Treated During Operation Inherent Resolve by a Forward Surgical Team.

INTRODUCTION: The combat experience during the re-entry stages of Operation Inherent Resolve was distinct from other recent operations, but there is no published literature regarding these "initial entry operations" experiences among forward surgical teams (FSTs) deployed to Role 2 facilities A descriptive analysis of patients treated by FSTs may provide valuable information for Role 2 surgical teams preparing to deploy in support of initial entry operations. The purpose of this analysis was to describe injury mechanism, wounding patterns and interventions performed by a small FST in the re-entry phase in Iraq. MATERIALS AND METHODS: From July 17, 2015 to January 31, 2016, a split surgical team with two surgeons and an ER physician documented care for all patients treated by their FST located in Iraq. Given their austere environment, FSTs have limited holding capacity, blood supply, and ability to triage and perform advanced procedures. Patients, who arrived to the Role 2 in asystole, were ineligible for the study. The patient population was Iraqi Security Forces as well as Iraqi civilians. No follow-up data were obtained. Using descriptive statistics, we described the basic demographics, health status, blood utilization, injury severity, and injury pattern of the patient population. RESULTS: The final study population included 300 Iraqi casualties. The majority of patients (96%) were discharged alive. Many patients were 16 years or older (96%), male (96%), Iraqi soldiers (86%), and injured during battle (96%). Over one-third of patients (35%) had a form of metabolic acidosis, 7% were hypothermic, and 18% were in shock at admission. The median amount of blood products used was 6 (interquartile ranges (IQR) = 2-12) units, while the median red blood cells:fresh frozen plasma ratio was 1.2:1. Six or more units of blood were given to 67 (22%) patients. The top three diagnoses were laceration (n = 197, 21%), penetrating injury (n = 185, 19%), and fracture (n = 174, 18%). A high number of injuries occurred in the extremities/pelvis and buttocks (n = 360, 38%) and in the abdomen and pelvic contents (n = 145, 15%). Over a quarter of patients (26%) had critical injuries (i.e., military injury severity score ≥25). CONCLUSIONS: Given the Role 2 configuration, these results demonstrate FSTs must be capable of managing critically ill patients with markedly limited resources. This management will include general operations in both adult and pediatric patients, resuscitation with a limited blood supply, and patient assessment with minimal to no diagnostic tools. This analysis can inform resident training, pre-deployment training, as well as sustainment training for surgeons after residency.

Factors influencing long-term weight loss after bariatric surgery.

BACKGROUND: Bariatric surgery provides sustained weight loss and improves comorbidities. However, long term data has shown that patients gradually regain weight after 1 year. Several factors have been associated with poor weight loss after bariatric surgery. OBJECTIVE: Our goal is to investigate factors associated with poor weight loss following laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). SETTING: Military academic medical center. METHODS: Retrospective review of 247 patients who underwent laparoscopic SG or RYGB between 2010-2012 at Eisenhower Army Medical Center and followed for 5 years postoperatively. Factors of age, type of surgery, sex, hypertension, depression, and type 2 diabetes (T2D) are analyzed in univariate and multivariate analysis with percent total weight loss (%TWL) and Body Mass Index (BMI) change as primary endpoints measured at 3 and 5 years. RESULTS: Average BMI change are maximized at 1 year and decreased at 3 and 5 years post-surgery. Age, diabetes, hypertension and type of surgery significantly influenced weight loss at 3 and 5 years on univariate analysis. However, patients with diabetes, hypertension and sleeve gastrectomy were significantly older than comparable control group. Multivariable analysis showed that age and type of surgery, not diabetes or hypertension, were associated with poor %TWL and BMI change at 3 and 5 years. CONCLUSION: While presence of hypertension and diabetes initially appeared to be associated with weight recidivism, their impacts were negligible on multivariable analysis. However, age and sleeve gastrectomy are independent risk factors. Our data can be used to counsel patients on expected weight loss after bariatric surgery.

Achieving Mastery of General Surgery Operative Skill in the Army Healthcare System.

INTRODUCTION: Operative case volumes for military surgeons are reported to be significantly lower than civilian counterparts. Among the concern that this raises is an inability of military surgeons to achieve mastery of their craft. MATERIAL AND METHODS: Annual surgical case reports were obtained from seven Army military treatment facilities (MTF) for 2012-2016. Operative case volume and cumulative operative time were calculated for active duty general surgeons and for individual MTFs. Subgroup analyses were also performed based upon rank. Results were extrapolated to calculate the amount of time it would take to reach a cumulative of 10,000 hours of operative time (the a priori definition for achieving mastery). RESULTS: One hundred and two active duty general surgeons operated at the seven MTFs during the study period and met the inclusion criteria. The average surgeon performed 108 ± 68 cases/year. The average surgeon operated 122 ± 82 hours/year. At this rate, it would take over 80 years to reach mastery of surgery. When stratified based upon rank, Majors averaged 113 ± 75 hours/year, Lieutenant Colonels averaged 170 ± 100 hours/year, and Colonels averaged 136 ± 101 hours/year (p < 0.05). When stratified based upon individual MTF, surgeons at the busiest facility averaged 187 ± 103 hours/year and those at the least busy facility averaged 85 ± 56 hours/year (p < 0.05). CONCLUSIONS: Obtaining mastery of general surgery is a nearly impossible proposition given the current care models at Army MTFs. Alternative staffing and patient care models should be developed if Army surgeons are to be masters at their craft.

Resolution of Fundic Gland Polyposis following Laparoscopic Magnetic Sphincter Augmentation and Subsequent Cessation of Proton Pump Inhibitors.

Gastric polyps occur from a variety of sources and are found commonly on upper endoscopy. We present the case of a 49-year-old female who presented for evaluation for antireflux surgery with a history of fundic gland polyposis who required twice-daily proton pump inhibitors (PPIs) for control of her gastric reflux. After verifying that she met criteria for surgery, she underwent an uncomplicated laparoscopic magnetic sphincter augmentation placement. With the cessation of PPIs following surgery, the fundic gland polyposis resolved. Fundic gland polyps may occur sporadically or within certain syndromes, such as familial adenomatous polyposis. Multiple possible inciting factors exist, including the use of PPIs. This is the first reported case of the resolution of numerous fundic gland polyps following the completion of laparoscopic magnetic sphincter augmentation.

Management of biliary symptoms after bariatric surgery.

BACKGROUND: Biliary disease requiring intervention can be complicated in the postbariatric surgery patient. METHODS: A retrospective review was completed to identify patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy from September 2001 to September 2014, and those who underwent biliary intervention were identified. RESULTS: A total of 1527 patients underwent bariatric surgery during the study period. Of the 1,112 patients without prior cholecystectomy, 91 (8%) had biliary symptoms requiring intervention. Ninety patients underwent cholecystectomy, with 86 successfully completed laparoscopically. Six patients required laparoscopy-assisted percutaneous transgastric endoscopic retrograde cholangiopancreatography along with cholecystectomy to clear gallstones from the common bile duct. Three patients who had undergone cholecystectomy before bariatric surgery developed primary common bile duct stones. CONCLUSIONS: Surgery for biliary disease after bariatric surgery can be completed successfully with minimal complications, and percutaneous transgastric endoscopic retrograde cholangiopancreatography has a high success rate of access to and clearance of the biliary tree.

Permacol interposition graft as an alternative to vein in contaminated wounds using a rabbit model.

BACKGROUND: Vascular injuries are common in trauma and often involve massive soft tissue injury and segmental arterial loss. Current practice uses either autogenous vein or polytetrafluorethylene (PTFE) for interposition grafting in arterial injuries. Decision making between autogenous or synthetic conduit pivots around the physiological state of the trauma patient. Vein is known to increase operative times in an already physiologically depleted patient, whereas synthetic graft can be simply pulled from the shelf. However, when used in contaminated wounds, PTFE is prone to chronic infection and subsequent graft failure. An alternative synthetic conduit resistant to infection would be ideal for such situations. Permacol (Tissue Science Laboratories, Inc, Andover, MA), a biosynthetic material, has demonstrated resistance to bacterial contamination in contaminated hernia repairs. When fashioned into a tubular structure, this material may be useful as an alternative vascular conduit in contaminated trauma wounds. METHODS: New Zealand white rabbits were randomized to one of 4 groups: Permacol graft (P) without bacterial contamination (n = 9), Permacol graft with bacterial contamination (CP; n = 9), autogenous vein graft without bacterial contamination (V; n = 9), or autogenous vein with bacterial contamination (CV; n = 9). All groups then underwent interposition grafting of the right common carotid artery. Grafts were contaminated by applying Staphylococcus aureus (1 × 10(5) colonies/0.1 mL) directly to the exposed surface of the graft on completion of the arterial repair. Each graft was then excised at day 42, and segments were collected for histologic evaluation, bacterial counts, and real-time polymerase chain reaction. RESULTS: Of the 36 rabbits used in this study, 3 animals in the CV group died within 72 hr of surgery. There was no difference in early mortality between P and V (0% vs. 0%; P = 1.0); however, early mortality was higher in the CV compared with the CP group (33% vs. 0%; P = 0.023). At 42 days, histologic evaluation of graft patency demonstrated no difference between P and V (67% vs. 33%; P = 0.157); however, patency was higher in CP than CV (56% vs. 12%; P = 0.040). In addition, no difference was found between the 2 contaminated groups in regard to the number of bacteria present on each graft material. CONCLUSIONS: Permacol as an interposition graft is a feasible alternative to vein in a contaminated setting and shows resistance to infection in a rabbit model. Future studies are needed to evaluate this material in larger animal models.

Upper gastrointestinal swallow study following bariatric surgery: institutional review and review of the literature.

BACKGROUND: The aim of this study was to determine the efficacy of routine upper gastrointestinal imaging following the three forms of laparoscopic bariatric surgery completed at our institution (laparoscopic Roux en Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LS), and laparoscopic adjustable gastric banding (LAGB)). METHODS: Radiograph reports were reviewed from the period of January 2005 to July 2010. During that time, 129 patients underwent LRYGB, 209 underwent LS, and 12 patients underwent LAGB. Of those patients, 120 LRYGB patients, 188 LS patients, and 11 LAGB patients underwent upper gastrointestinal studies on postoperative days (POD) 1 or 2. RESULTS: Of the 319 total patients who underwent UGI, no contrast leaks were found. One LRYGB patient was found to have stenosis of the jejunojejunal anastomosis and was taken to the operating room for revision. A total of ten patients went on to develop leaks: four LRYGB patients, six LS patients, and zero LAGB patients. CONCLUSIONS: The results of our study show that a positive UGI study for stricture has a specificity of 100 %. In terms of leak, which offers a much higher risk of significant morbidity and mortality, UGI was unable to find any on postoperative days 1 or 2. Based on the results of this study, our institution has stopped completing routine UGI on POD 1 following bariatric surgery.

Amyand hernia repaired with Bio-A: a case report and review.

A 53-year-old man with an Amyand hernia with indirect and direct components was repaired with a Bio-A (Gore, Newark, Delaware) plug and a patch made of Bio-A tissue reinforcement material. The repair of an Amyand hernia addresses the pathology of the appendix as well as the hernia. We report a case in which a plug and patch repair was undertaken using Bio-A implants in a clean-contaminated field with no signs of infection or recurrence in the follow-up period, and we review the literature regarding the diagnosis and repair of an Amyand hernia.

Comparison of staple-line leakage and hemorrhage in patients undergoing laparoscopic sleeve gastrectomy with or without Seamguard.

Laparoscopic sleeve gastrectomy (LSG) has been recognized as a primary procedure for the surgical management of morbid obesity. Staple-line leaks and hemorrhage are two associated complications. Staple-line buttressing materials have been suggested to decrease these complications. When used during LSG, few published papers exist that compare the incidence of leak or hemorrhage to that of nonreinforced staple-lines. The purpose of this study was to compare the incidence of leak and hemorrhage in patients who did and did not receive reinforcement with Seamguard (W.L. Gore & Associates, Flagstaff, AZ). This is a retrospective analysis of patients undergoing LSG. All patients met National Institutes of Health criteria and each had an extensive preoperative evaluation. Data was collected from inpatient and outpatient medical records. Fifty-nine patients received reinforcement and 80 patients did not. There was no significant difference in mean body mass index, age, or gender make-up between the two groups. The overall incidence of leak was 3.60 per cent. The incidence was 3.39 per cent in patients who received reinforcement and 3.75 per cent in those who did not. This was not statistically significant. There was no incidence of staple-line hemorrhage in either group. There is no conclusive evidence that Seamguard reduces staple-line leakage or hemorrhage. Studies involving a larger number of patients are necessary before recommending staple-line reinforcement.

Cerebral air embolism following removal of central venous catheter.

Cerebral air embolism occurs very seldom as a complication of central venous catheterization. We report a 57-year-old female with cerebral air embolism secondary to removal of a central venous catheter (CVC). The patient was treated with supportive measures and recovered well with minimal long-term injury. The prevention of air embolism related to central venous catheterization is discussed.