The Order of Operative Repair Does Not Influence Outcomes in Patients with Concomitant Popliteal Artery and Orthopedic Injuries.

BACKGROUND: The most challenging lower extremity traumatic injuries involve concomitant vascular and orthopedic injuries with amputation rates approaching 50%. Controversy exists as to how to prioritize the vascular and orthopedic repairs. We reviewed patients with popliteal artery and lower extremity orthopedic injuries to analyze the sequence of the vascular and orthopedic repairs on outcomes. METHODS: All adult patients with a diagnosis of concomitant popliteal artery and lower extremity fracture or dislocation were identified through a review of an institutional trauma registry performed at a level 1 trauma center from 2014 to 2019. Patient demographics, timing of presentation, injury severity score (ISS), surgical interventions, and limb outcome data were collected and examined. The sequence of operative repairs and factors influencing the operative order were analyzed. RESULTS: Twenty-nine patients were treated for popliteal artery injuries. Twelve of these 29 patients had concomitant popliteal artery and orthopedic fractures requiring surgical repair. Injury mechanisms included both blunt (50%, 6/12) and penetrating trauma (50%, 6/12); the majority involved femur fractures (58%, 7/12). Vascular repair included arterial bypass (75%, 9/12) or interposition grafts (25%, 3/12). Orthopedic repair included external fixation (83%, 10/12) and open reduction internal fixation (17%, 2/12). Vascular repair was performed first in 7/12 limbs (58%). Patients having vascular repair first had a trend toward lower blood pressure on arrival (P = 0.068). There was no significant difference in emergency department to operating room (OR) time, OR time, ISS, mangled extremity severity score, estimated blood loss, or blood transfusion for the sequence of operative repair. Fasciotomy was nearly ubiquitous, present in 11/12 patients (92%). There were no graft complications related to orthopedic manipulation, and there were no reported limb-length to graft-length discrepancies. Early limb salvage trended lower in the cohort with revascularization first (71% vs. 100%, P = 0.19). Of the remaining limbs available for follow-up, limb salvage at 4.25 years is 100%. CONCLUSIONS: In this small study of patients with concomitant lower extremity popliteal artery and orthopedic injuries, the order of operative repair does not appear to influence the success of revascularization.

Trends in Preoperative Imaging Prior to Elective Carotid Endarterectomy in the Southern California Vascular Outcomes Improvement Collaborative.

BACKGROUND: Duplex ultrasound (DUS) has been an important imaging modality for carotid bifurcation disease due to its low cost and noninvasive nature. Over the past decade, computed tomography angiography (CTA) has replaced conventional angiography (CA) due to safety and availability. There are significant differences in cost and patient exposures between CTA and DUS. The objective of this study is to analyze the trends in preoperative imaging modalities in the Southern California region for elective carotid endarterectomies (CEA). METHODS: A retrospective review of the Southern California Vascular Outcomes Improvement Collaborative (SoCal VOICe) was performed. All elective CEA procedures were identified from January 2011 through May 2020. Data included all preoperative imaging modalities used. An analysis was performed of the types and numbers of studies obtained. The trends in the usage of single and multiple preoperative studies and the trends in use of DUS versus CTA were analyzed. RESULTS: From January 2011 to May 2020, 2,519 elective CEAs were entered into the regional database. Of the 2,336 eligible cases (183 excluded due to incomplete data), 38% were for symptomatic (Sx) and 62% for asymptomatic (ASx) carotid disease. Preoperative imaging studies ordered included 56% DUS, 28% CTA, 6% magnetic resonance angiography, and 10% CA. Single imaging studies were used in 56.3% of cases, 2 studies in 40.4%, and >2 studies in 3.3%. A majority of both Sx and ASx patients undergoing elective CEA had only a single preoperative imaging study. ASx patients were more likely to have a single study than Sx patients (P = 0.0054). DUS was the most frequent single study ordered in both Sx and ASx patients, 37.4% and 41.4%, respectively. The trend over time shows a decreasing use of DUS and an increasing use of CTA for both Sx and ASx patients. In 2020, CTA overtook duplex as the most frequently ordered study for Sx patients. The average number of imaging studies per procedure per year for both Sx and ASx patients has not changed substantially at approximately 1.5 studies. In addition, the overall trend shows that although a single preoperative study was more common than 2 or more studies for elective CEA, single studies were more common for ASx patients, whereas the use of 2 or more studies was more common for Sx patients. The overall trend among three different time periods, 2011-2013, 2014-2016, and 2017-2020 shows that for both Sx and ASx patients, the use of single DUS studies has decreased over time (P < 0.001), whereas the use of single CTA studies has increased over time (P < 0.001). The use of CTA varied widely by a study center ranging from 12-53% for Sx and 10.5-75% for ASx patients. CONCLUSIONS: Over the past decade, most patients undergoing elective CEA in the SoCal VOICe had only a single preoperative imaging study with DUS as the most frequent sole study in both Sx and ASx patients. However, as a single study, CTA is becoming more frequently used than DUS. Further investigation into the variation in practice may help standardize imaging prior to CEA and control healthcare costs.

Surgical and Endovascular Management of Extracranial Carotid Artery Aneurysms, Outcomes From the American College of Surgeons, National Surgical Quality Improvement Program.

OBJECTIVES: Extracranial carotid artery aneurysms (ECAA) are rare and consequentially understudied; yet multiple management strategies for ECAA have been pursued. The goal of this study was to compare rates of stroke and cardiac events following surgical or endovascular management of ECAA utilizing the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP). METHODS: The ACS-NSQIP database was queried for patients with both selected procedure codes and diagnostic codes specific for ECAA. 139 patients, 0.2% of carotid procedures, were located within ACS-NSQIP from 2013-2017. RESULTS: The endovascular group (n = 19) had a higher proportion of emergency procedures than the open surgical group (n = 120). Post-operative strokes in the endovascular group (n = 3, 15.8%) were not significantly higher than the open surgical group (n = 5, 4.2%; P = 0.078). One cardiac event (0.7%) in the cohort occurred in the surgical group. DISCUSSION: This study provides insight into trends in national management of ECAA. Post-operative stroke rates trended higher with endovascular approaches, perhaps due to traumatic presentation as this group had a higher proportion of emergency procedures. Additionally, this study suggests patients with ECAA may have less cardiac burden than their peers with carotid stenosis.

Shock Index as a Marker for Mortality Rates in Those Admitted to the Medical Intensive Care Unit from the Emergency Department.

Objective Shock index (SI) is defined as the heart rate divided by systolic blood pressure. Studies have shown a correlation between the shock index and mortality in trauma patients in prehospital settings and in the emergency department (ED). The objective of this study was to identify the utility of SI in predicting mortality in the medical intensive care unit (MICU) patients admitted from the ED and transfers from the floor to MICU.  Design We performed a retrospective analysis of adult patients admitted to the MICU at our urban trauma hospital between January 2015 through August 2015 using ED vital signs to calculate the shock index and identify inpatient deaths. Similar data were examined for inpatient transfers to the MICU. Results Nine hundred and fifty patients were included in the study; 743 had an SI ≤ 0.99 with a mortality rate of 15.9%. Two hundred and seven patients had a SI ≥ 1.00 with a mortality rate of 22.7%. A higher SI was significant for mortality. There was no statistical significance in SI and mortality rate for patients transferred from the medical floor to the ICU. Conclusions Patients with an SI ≥ 1.00 from initial ED vital signs correlated with a higher mortality rate. In patients transferred from the floor to MICU, SI ≥ 1.00 did not correlate with a higher mortality rate.

Safety and efficiency of gasless laparoscopy: a systematic review protocol.

BACKGROUND: Gasless laparoscopy, developed in the early 1990s, was a means to minimize the clinical and financial challenges of pneumoperitoneum and general anaesthesia. It has been used in a variety of procedures such as in general surgery and gynecology procedures including diagnostic laparoscopy. There has been increasing evidence of the utility of gasless laparoscopy in resource limited settings where diagnostic imaging is not available. In addition, it may help save costs for hospitals. The aim of this study is to conduct a systematic review of the available evidence surrounding the safety and efficiency of gasless laparoscopy compared to conventional laparoscopy and open techniques and to analyze the benefits that gasless laparoscopy has for low resource setting hospitals. METHODS: This protocol is developed by following the Preferred Reporting Items for Systematic review and Meta-Analysis-Protocols (PRISMA-P). The PRISMA statement guidelines and flowchart will be used to conduct the study itself. MEDLINE (Ovid), Embase, Web of Science, Cochrane Central, and Global Index Medicus (WHO) will be searched and the National Institutes of Health Clinical Trials database. The articles that will be found will be pooled into Covidence article manager software where all the records will be screened for eligibility and duplicates removed. A data extraction spreadsheet will be developed based on variables of interest set a priori. Reviewers will then screen all included studies based on the eligibility criteria. The GRADE tool will be used to assess the quality of the studies and the risk of bias in all the studies will be assessed using the Cochrane Risk assessment tool. The RoB II tool will assed the risk of bias in randomized control studies and the ROBINS I will be used for the non-randomized studies. DISCUSSION: This study will be a comprehensive review on all published articles found using this search strategy on the safety and efficiency of the use of gasless laparoscopy. The systematic review outcomes will include safety and efficiency of gasless laparoscopy compared to the use of conventional laparoscopy or laparotomy. TRIAL REGISTRATION: The study has been registered in PROSPERO under registration number: CRD42017078338.

Amyand's hernia presenting as an unusual inguinal mass: a case report.

Accounting for approximately 0.4-0.6% of all inguinal hernias, Amyand's hernia is a rare condition in which a vermiform appendix is found in an inguinal hernia sac. It is most commonly found in males and in the pediatric population. Since Claudius Amyand's first reported case in 1736, there have only been a total of 228 documented cases of the Amyand's hernia. Due to its rarity, the pathophysiology and risk factors of the condition are still unclear. Some theorize that it is secondary to a patent processus vaginalis or perhaps the presence of a fibrous band between the hernia sac and testes. Amyand's hernia usually presents as an incarcerated or strangulated hernia, but its presentation can be quite variable. We report an unusual case of an Amyand's hernia presenting as an enlarging painful mass on the right lateral edge of the mons pubis, resembling an abscess.

Biliary atresia in Vietnam: Management and the burden of disease.

BACKGROUND: Biliary atresia is an idiopathic, neonatal liver disease of the bile ducts. The natural evolution of biliary atresia is known in developed countries. This study describes the clinical course of biliary atresia in Vietnam, a developing country. METHODS: Chart reviews were undertaken of patients treated with or without the Kasai procedure between January 2010 and July 2013 at a children's hospital in Vietnam. RESULTS: Of 287 children with biliary atresia, 149 (52%) were treated without the Kasai procedure and 138 (48%) were treated with the Kasai procedure. Median age at diagnosis was 2.4 months for children treated without the Kasai procedure vs 2.3 months for those treated with the procedure. The percentages of patients in the group treated without the Kasai procedure presenting at <2 months, 2 to <3 months, 3 to <4 months, 4-6 months, and >6 months of age were 31%, 35%, 15%, 10%, and 9%, respectively, compared to those treated with the Kasai procedure at 36% (P = .38), 44% (P = .12), 16% (P = 1.0), 4% (P = .037), and 0% (P < .001), respectively. The group treated without the Kasai procedure had 1- and 2-year survivals of 52% and 28%, respectively (median survival 6.6 months); in contrast, the group treated with the Kasai procedure had 1- and 2-year transplant-free survivals of 84% and 71%. No patients were treated by liver transplantation because of lack of a liver transplantation program in Vietnam. CONCLUSION: The majority of biliary atresia in Vietnam remains untreated despite early presentation and reasonable outcomes after a Kasai procedure relative to Western countries. These data illustrate the high health care burden for biliary atresia in Vietnam and the need to improve education about biliary atresia and its treatment.