Evaluation of Piperacillin-Tazobactam for Antibiotic Prophylaxis in Traumatic Grade III Open Fractures.

Background: Broad-spectrum antibiotic agents are sometimes utilized for prophylaxis of Gustilo grade III open fractures. However, this practice is not recommended by current guidelines, and it is unknown how patient outcomes are impacted. This study aimed to determine if prophylaxis with piperacillin-tazobactam (PT) results in different rates of infection versus guideline-concordant therapy (GCT). Patients and Methods: This was a single-center, retrospective cohort study of adult trauma patients with Gustilo grade III open long bone fractures admitted between January 2008 and August 2018. The primary outcome of infection (superficial or deep) at six weeks and secondary outcomes of delayed union, nonunion, Clostridioides difficile, and development of resistant organisms were abstracted from medical records. Guideline-concordant therapy was defined as a first-generation cephalosporin with or without an aminoglycoside. Univariable and multivariable analyses controlling for injury severity score (ISS) were performed. Results: One hundred twenty patients were included; 97 (81%) received PT, 23 (19%) received GCT. Common injury mechanisms were motor vehicle/motorcycle accident (57%) and falls (17%), and a majority involved a lower extremity (65%). Baseline characteristics were similar except higher median ISS in PT (14; interquartile range [IQR], 9-22) versus GCT (9; IQR, 9-14). Guideline-concordant therapy was given for a median of four (range, 2-8) days and PT for six (range, 3-11) days (p = 0.078). On univariable analysis, PT patients had more infections at six weeks (23.7% vs. 4.3%; p = 0.042), but multivariable analysis demonstrated no difference (odds ratio [OR], 5.81; 95% confidence interval [CI], 0.73-46.25; p = 0.096). Patients receiving prophylaxis with PT had a longer median length of stay at 16 days (range, 10-22) versus nine days (range, 4-16). No statistically significant differences in delayed union, non-union, Clostridioides difficile, or development of resistant organisms were observed. Conclusions: Broad-spectrum antibiotic prophylaxis with PT did not improve infection rates compared to GCT, suggesting it may not be warranted.

Surgical outcomes of ERCP-guided transpapillary gallbladder drainage versus percutaneous cholecystostomy as bridging therapies for acute cholecystitis followed by interval cholecystectomy.

BACKGROUND: Select patients with acute cholecystitis (AC) are not candidates for index cholecystectomy. We compared the influence of ERCP-guided transpapillary gallbladder drainage (ERGD) versus percutaneous cholecystostomy (PC) on delayed cholecystectomy outcomes. METHODS: Consecutive patients undergoing ERGD or PC for AC from January 2007 to October 2018 were included. Primary outcome was the rate of conversion to open cholecystectomy and perioperative complications in groups. RESULTS: The study included 52 patients with ERGD and 140 with PC prior to cholecystectomy (median 68 days [IQR: 47-105.5]). Technical success was higher in the PC group (100% vs 91%; P = 0.0004). There was a nonsignificant trend to lower postoperative complications with ERGD (30.7% vs 43.5%; P = 0.07). No difference in conversion to open cholecystectomy OR: 1.5 (95% CI: 0.68-3.65; P = 0.28) or severity of complications (Clavien-Dindo grade >2) OR: 0.60, (95% CI: 0.19-1.87; P = 0.38) was noted between the ERGD and PC groups. PC was associated with higher rates of unplanned repeat intervention (16.4% vs 7.7%; P = 0.02). CONCLUSION: ERGD is suitable for patients with AC who is candidates for delayed cholecystectomy and should be considered for gallbladder drainage in patients with concomitant choledocholithiasis or cholangitis who require ERCP.

Recurrence and Long-Term Survival Following Segmental Colectomy for Right-Sided Colon Cancer in 813 Patients: a Single-Institution Study.

BACKGROUND: Controversy exists regarding optimal surgical approach to right-sided colon cancer due to increasing complete mesocolic excision outcome data; yet, scarce long-term surgical and oncologic outcome data from high-volume centers following right segmental resections without complete mesocolic excision make comparisons difficult to interpret. We report long-term outcomes following standard mesocolic excision for right-sided colon adenocarcinoma. METHODS: A retrospective review of a prospective database was conducted of all consecutive adult patients undergoing surgery for a right-sided colon adenocarcinoma between 2000 and 2007. Demographics, oncologic, operative, and pathologic details are reported. Primary endpoints consisted of overall survival and recurrence. Patients with stage IV and recurrent disease were excluded. RESULTS: Eight hundred thirteen patients were identified. Majority of tumors were stage II (n = 318, 39%). Adjuvant chemotherapy was administered to 228 patients (28%). Recurrence was observed in 97 patients (12%), at median 1.3 years. Recurrence was most commonly distant (n = 73, 9%). At median follow-up 7.3 years, 5- and 10-year overall survival was 72.4%, and 48.6%, respectively. Five- and 10-year disease-free survival was 67% and 45.8%, respectively. Multivariable analysis demonstrated that TNM stage was a significant predictor of recurrence. For disease-free survival, T stage, and N stage were significant on multivariate analysis. Multivariable predictors of overall survival included age, number of lymph nodes removed, N stage, and adjuvant chemotherapy use. CONCLUSIONS: Excellent long-term outcomes from a large cohort of patients with non-metastatic, right colon adenocarcinoma treated by segmental colectomy without complete mesocolic excision are reported. The majority of recurrences were distant.

Adrenocortical carcinoma with inferior vena cava tumor thrombus.

BACKGROUND: The safety, efficacy, and prognostic implications of resection of adrenocortical carcinoma with inferior vena cava tumor thrombus are poorly described. METHODS: A retrospective review was performed during a 30-year period on patients who underwent resection of locally advanced, nonmetastatic adrenocortical carcinoma. We compared patients with and without inferior vena cava tumor thrombus, examining perioperative characteristics, completeness of resection, mortality, and survival. RESULTS: We identified 65 patients who underwent resection of locally advanced (T4N0 and T4N1) adrenocortical carcinoma (28 patients with inferior vena cava tumor thrombus, 37 noninferior vena cava tumor thrombus). Rate of complete resection, adjuvant chemotherapy, and short-term postoperative morbidity was similar between groups. Overall survival was similar at 12-months. At 24 months overall survival was less in the inferior vena cava tumor thrombus group (59% vs 30%, P = .04). Differential survival through 60-month follow-up favored the noninferior vena cava tumor thrombus group (36% vs 0%, P = .001). Subgroup analysis including only patients with complete resection demonstrates similar survival at 24-months but at 36-months survival favored the noninferior vena cava tumor thrombus patients (65% vs 29%, P = .047) and this continued through 60 months (40% vs 0%, P = .049). CONCLUSION: Attempt at complete resection of adrenocortical carcinoma with inferior vena cava tumor thrombus seems justified particularly as short-term safety and survival are similar to patients without inferior vena cava tumor thrombus. However, survival beyond 36-months is limited in patients with inferior vena cava tumor thrombus. Patients being evaluated for resection in the setting of inferior vena cava tumor thrombus should be selected carefully.

Proximal intestinal diversion is associated with increased morbidity in patients undergoing elective colectomy for diverticular disease: an ACS-NSQIP study.

BACKGROUND: Elective colectomy for diverticular disease is common. Some patients undergo primary resection with proximal diversion in an effort to limit morbidity associated with potential anastomotic leak. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried. All patients undergoing a single, elective resection for diverticular disease from 2005 to 2011 were analyzed. Thirty-day outcomes were reviewed. Factors predictive of undergoing diversion and the risk-adjusted odds of postoperative morbidity with and without proximal diversion were determined by multivariable logistic regression models. RESULTS: Fifteen thousand six hundred two patients undergoing non-emergent, elective resection were identified, of whom 348 (2.2 %) underwent proximal diversion. Variables predictive for undergoing proximal diversion included age ≥65 years, BMI ≥30, current smoking status, corticosteroid use, and serum albumin <3.0 g/dL. Multivariable analysis demonstrated that diversion was associated with significantly increased risk of surgical site infection (OR = 1.68), deep venous thrombosis (OR = 5.27), acute renal failure (OR = 5.83), sepsis or septic shock (OR = 1.75), readmission (OR = 2.57), and prolonged length of stay (OR = 3.35). CONCLUSIONS: Proximal diversion in the setting of elective segmental colectomy for diverticular disease is uncommon. A combination of preoperative factors and intraoperative factors drives the decision for diversion. Patients who undergo diversion experience increased postoperative morbidity. Surgeons should have a low index of suspicion for postoperative complications and be prepared to mitigate their effect on the patient's outcome.

Surgical outcomes in adults with benign and malignant sacrococcygeal teratoma: a single-institution experience of 26 cases.

BACKGROUND: Adult sacrococcygeal teratomas are rare, and limited data exist on their management and outcomes following surgery. OBJECTIVE: The aim of this study was to review the outcomes in adult patients undergoing surgery for sacrococcygeal teratomas. DESIGN: A retrospective review of our prospectively maintained surgical pathology and tumor registries was conducted. SETTING: This study was conducted at the Mayo Clinic in Rochester. Information was collected on patients treated between 1980 and 2013. PATIENTS: A total of 26 patients with sacrococcygeal teratoma were identified (19 female), with a median age of 37.5 years. Malignancy was seen in 5 patients. MAIN OUTCOME MEASURES: Data on demographics, clinical presentation, tumor pathology, adjuvant therapy, surgical approach, surgical margins, use of preoperative biopsy, radiological investigations, morbidity, mortality, and local recurrence was collected. Complications were assessed by using the Clavien-Dindo system of classification. RESULTS: Patients most commonly presented with pelvic pain (n = 16) and/or a palpable mass (n = 15). On radiology, 8 lesions were purely cystic, 14 were mixed, and 4 were solid; teratoma was suspected as a diagnosis in 8 patients. Preoperative biopsy (13 patients) had 100% concordance with final pathology. Median tumor size was 6 cm, and the surgical approach was posterior only (n = 15), anterior only (n = 5), and combined anterior-posterior (n = 6). Of 5 patients with malignancy, 3 died of recurrent disease. LIMITATIONS: Limitations of this study include the small number of patients, the long study period, and the heterogeneous nature of these tumors. CONCLUSION: Presacral teratomas require multidisciplinary management and have a risk of malignant transformation. They are more common in females, and the majority are intrapelvic in location in adults. We recommend clinical evaluation, radiological investigation, and image-guided biopsy in all suspicious presacral lesions. A treatment algorithm has been designed to improve the management of these rare tumors.

Operative intervention for recurrent adrenocortical cancer.

INTRODUCTION: Adrenocortical cancer (ACC) recurs despite apparent complete resection. We examined the survival and palliative benefit of resection for recurrent ACC. METHODS: A review of all patients undergoing operation for ACC between 1980 and 2010 at our institution was performed in which we compared resection with nonoperative therapy. RESULTS: Overall, 164 patients underwent operation for ACC, 125 of whom underwent a complete resection (R0). Recurrence occurred in 93 R0 patients (median, 15 months; range, 1.5-150 months). Symptoms at recurrence were present in 71% (66/93), including pain (34%) and hormone excess (43%). There were 67 patients who underwent reoperation for recurrence. Forty-eight of 67 patients underwent R0 resection for recurrence. Operative patients had a greater overall operative versus nonoperative management or no therapy (65 months vs 6 months, P < .01). Median survival for nonoperatively managed patients (226 days) and those undergoing no therapy (179 days) was less than for debulking (1,272 days, P = .002). R0 for recurrence (P = .005) and a disease-free interval >6 months (P < .001) were associated with survival after operation, whereas original tumor size (P = .47), grade (P = .8), and stage (P = .23) were not. Pain and hormonal symptoms improved in 84% of operative patients versus 29% of nonoperatively managed patients (P = .005). Debulking had similar symptomatic improvement to R0 resection (P = .52). CONCLUSION: Patients with recurrent ACC can benefit from operative intervention with improvement in survival and symptoms. Patients with a disease-free interval >6 months and complete resection are likely to benefit from resection of the recurrence, but the near universal improvement in symptoms may expand the criteria for operation in recurrent ACC.

Resection of a giant primary synovial sarcoma of the inferior vena cava extending into the right atrium with caval reconstruction under cardiopulmonary bypass and circulatory arrest.

BACKGROUND: Synovial sarcoma primarily arises in para-articular locations of the extremities. However, numerous unique sites of origin have been reported. There are only 5 known cases of primary intravascular synovial sarcoma. METHODS: We present the second reported case of synovial sarcoma arising from the inferior vena cava (IVC) in a 41-year-old woman with progressive fatigue, abdominal distension, and lower-extremity swelling. This is the first known case with a monophasic histological subtype. RESULTS: The tumor arose from the retrohepatic IVC with cephalad extension into the right atrium. Excision required cardiopulmonary bypass and deep hypothermic circulatory arrest, followed by bovine pericardial patch reconstruction of the IVC. CONCLUSIONS: Primary synovial sarcoma of the IVC is rare. The use of cardiopulmonary bypass with or without deep hypothermic circulatory arrest may be required if there is tumor extension into the heart. Bovine pericardium is an excellent material for caval reconstruction.

Can secondary extremity compartment syndrome be diagnosed earlier?

BACKGROUND: In 2002, our institution published a 5-year retrospective review of 10 patients who developed secondary extremity compartment syndrome (SECS) with a mortality rate of 70%. Since then, we have aggressively screened for the development of SECS in high-risk patients. We postulate that awareness of SECS and vigilant monitoring for its development would result in earlier diagnosis and treatment and improved outcome. METHODS: Retrospective review of all patients at a level I trauma center developing SECS from 2002 to 2006. Data collected included demographics, mechanism of injury, injury complex, blood transfused prior to development of SECS, affected extremities, creatinine, creatine phosphokinase, management, and outcome. RESULTS: Seventeen of 11,468 trauma patients (.148%) developed SECS. Mean admission hematocrit was 31.7 +/- 8.9, mean admission base deficit was -13.3, mean worst base deficit was -17.8, and average Injury Severity Score was 36.3 +/- 16.6. Patients received 20.9 +/- 11.0 units of blood and 24.6 +/- 14 L of crystalloid prior to the development of SECS. Average time from admission to diagnosis of the SECS was 32.6 hours. Acute renal failure developed in 6 (35%) patients; 4 required dialysis, and 3 died. The number of affected extremities ranged from 1 to 4. Of the 46 affected extremities, 39 were salvaged and 7 required amputation. Mortality was 35.3%. CONCLUSIONS: SECS is an uncommon, but devastating complication in severely injured patients with hypotension undergoing massive transfusion, and developing systemic inflammatory response syndrome. Vigilance increases detection. While the overall mortality was reduced by half, patients requiring dialysis have a 75% mortality.