In- and out-of-hospital outcomes following surgical stabilization of rib fractures in 80 years and older: A single-institution experience.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) has demonstrated benefit in patients with flail chest and multiple displaced fractures. There is mounting evidence for SSRF following chest wall injury (CWI) for the geriatric trauma population. A recent multi-center retrospective study highlighted a mortality benefit even for those patients aged 80 years and older. The objective of this investigation was to review our institutional experience with both in- and out-of-hospital outcomes within this patient population following SSRF. METHODS: A retrospective review of patients 80 years and older was performed at a high-volume level 2 trauma center from 2017 to 2021. SSRF volume is routinely >60 cases per year. Perioperative, inpatient, and outpatient data were collected as available. Primary outcomes were inpatient and 90-day mortality. Secondary outcomes included discharge on narcotics and freedom from narcotics at 30 days. RESULTS: 50 patients were included for review. Mean age was 86 years and mechanism of injury was most often fall. 28 of 50 (56%) patients had flail chest (radiographic). Mean number of ribs fixated was 4.7 and time to surgery 2.5 days. Inpatient mortality was 3/50 (6%), 90-day mortality was 9/50 (18%) of which three were attributable primarily to CWI (6/50, 12%). Of patients with follow-up of 1 year and beyond, 27/28 were alive (96%). With respect to narcotic consumption, 45% (21/47) were discharged on narcotics with 90% (28/31; N limited by missing data) being narcotic-free at 30 days. CONCLUSION: In this high-risk patient population, inpatient mortality was comparably low to prior reports, though 90-day mortality was doubled when incorporating CWI-related deaths. Narcotic use was seen in the minority of patients upon discharge, and most progressed to being narcotic-free at 30 days post-hospitalization. Inpatient outcomes alone may not adequately define both the benefit and risk of SSRF performed in patients 80 years and older.

Surgical stabilization of severe chest wall injury following cardiopulmonary resuscitation.

BACKGROUND: Cardiopulmonary resuscitation (CPR) contributes to significant chest wall injury similar to blunt trauma. With benefits realized for surgical stabilization of rib fractures (SSRFs) for flail injuries and severely displaced fractures following trauma, SSRF for chest wall injury following CPR could be advantageous, provided good functional and neurologic outlook. Experience is limited. We present a review of patients treated with SSRF at our institution following CPR. METHODS: A retrospective analysis of patients undergoing SSRF following CPR was performed between 2019 and 2020. Perioperative inpatient data were collected with outpatient follow-up as able. RESULTS: Five patients underwent SSRF over the course of the 2-year interval. All patients required invasive ventilation preoperatively or had impending respiratory. Mean age was 59 ± 12 years, with all patients being male. Inciting events for cardiac arrest included respiratory, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and anaphylaxis. Time to operation was 6.6 ± 3 days. Four patients demonstrated anterior flail injury pattern with or without sternal fracture, with one patient having multiple severely displaced fractures. Surgical stabilization of rib fracture was performed appropriately to restore chest wall stability. Mean intensive care unit length of stay was 9.8 ± 6.4 days and overall hospital length of stay 24.6 ± 13.2 days. Median postoperative ventilation was 2 days (range, 1-15 days) with two patients developing pneumonia and one requiring tracheostomy. There were no mortalities at 30 days. One patient expired in hospice after a prolonged hospitalization. Disposition destination was variable. No hardware complications were noted on outpatient follow-up, and all surviving patients were home. CONCLUSION: Chest wall injuries are incurred frequently following CPR. Surgical stabilization of these injuries can be considered to promote ventilator liberation and rehabilitation. Careful patient selection is paramount, with surgery offered to those with reversible causes of arrest and good functional and neurologic outcome. Experience is early, with further investigation needed. LEVEL OF EVIDENCE: Therapeutic, Level V.

Accuracy of endoscopic ultrasound in the evaluation of cystic pancreatic neoplasms: a community hospital experience.

OBJECTIVES: Reports on the use of endoscopic ultrasound (EUS) in differentiating benign, premalignant, and malignant pancreatic lesions have been widely variable, particularly with cystic neoplasms. We evaluated the use of EUS for cystic pancreatic lesions in a community hospital setting. METHODS: All patients who underwent EUS for cystic pancreatic neoplasms from 2007 to 2010 were reviewed. A final EUS diagnosis was determined based on the examiner's impression and fine-needle aspiration results if available. Lesions were stratified as benign, premalignant, or malignant. Patients underwent surgical resection, serial imaging studies, or medical oncology/palliative care consultation as indicated. RESULTS: One hundred eighteen patients with cystic pancreatic lesions underwent EUS during the study period. Endoscopic ultrasound diagnoses included 75 benign (63.6%), 35 premalignant (29.7%), and 8 malignant (4.2%) lesions. Thirty-eight patients (32.2%) underwent surgery, 77 (65.3%) were monitored with imaging, and 3 (2.5%) had unresectable malignancies. Elevated carcinoembryonic antigen levels showed a trend toward predicting mucinous cysts (P = 0.062). Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for cystic lesions were 87.3%, 86.8%, 87.5%, 76.7%, and 93.3%, respectively. CONCLUSIONS: Endoscopic ultrasound is a valuable diagnostic modality in the evaluation of cystic pancreatic neoplasms in a community hospital setting.

Benefits of transperitoneal approach to bilateral pretransplant laparoscopic nephrectomies in pediatric patients.

INTRODUCTION: Pediatric renal transplant patients may require native nephrectomy to avoid complications at the time of kidney transplantation. We have performed unilateral and bilateral transperitoneal pretransplant laparoscopic nephrectomies (PLNs), followed by living-related renal transplantation. The benefits of transperitoneal versus retroperitoneal dissection remain controversial. SUBJECTS AND METHODS: A retrospective review of patients who underwent unilateral or bilateral transperitoneal PLNs between May 1, 2001 and April 30, 2009 was performed. A transperitoneal approach was used in all patients. RESULTS: Eight patients underwent transperitoneal PLN. Four patients were female, and the average age was 91 months (range, 9-199 months). Five of the cases involved bilateral nephrectomy. Average operating times, including hemodialysis catheter placement and other procedures, was 4.93 hours (range, 4.25-5.97 hours) for bilateral PLN and 3.93 hours (range, 2.57-5.48 hours) for unilateral PLN. The average hospital stay was 5.9 days. All patients underwent successful renal transplantation following PLN without rejection at an average 2.3 years of follow-up. CONCLUSIONS: PLN appears to be an effective, safe method of removing potentially problematic, diseased kidneys prior to planned renal transplantation. A transperitoneal technique using four midline ports affords excellent access to both kidneys and, more importantly, allows for additional procedures to be completed simultaneously.

Selective laparoscopic approach in suspected gallbladder malignancy.

BACKGROUND AND OBJECTIVES: We examined patients with clinical findings that are concerning for gallbladder malignancy to determine the incidence of pathology-confirmed malignancy and to discover factors that may be used to determine which patients may be initially treated with a laparoscopic approach. METHODS: All patients referred to a surgical oncologist with preoperative findings that are concerning for gallbladder malignancy who had not undergone previous surgical resection from 2005 to 2011 were reviewed. Variables collected included demographics, imaging, operative findings, and final pathology. Patients were grouped into 3 categories based on preoperative findings: gallbladder mass, irregular wall thickening, and abnormal intraoperative findings on previous diagnostic laparoscopy. RESULTS: Twenty-nine of 4474 patients evaluated for gallbladder pathology during the study period met the inclusion criteria. Preoperative imaging included computed tomography, ultrasonography, and magnetic resonance imaging. Twelve patients had multiple imaging studies. Eight patients were initially treated with a laparoscopic approach with 3 conversions to an open procedure. Forty-eight percent of patients had pathology-confirmed malignancy. Patients without a discrete mass on imaging were more likely to have benign disease (P = .04). CONCLUSIONS: Our results demonstrate that >50% of patients with suspicious preoperative findings had benign pathology, suggesting that the initial laparoscopic approach in selected patients may be appropriate.

Temporal artery biopsy as a means of diagnosing giant cell arteritis: is there over-utilization?

Temporal artery biopsy (TAB) is often recommended for patients suspected of having temporal arteritis. The sensitivity of TAB varies widely and is dependent upon a number of factors (e.g., number of biopsy specimens, corticosteroid pretreatment, specimen length). The purpose of this study was to determine the clinical utility of TAB in patients who are suspected of having giant cell arteritis (GCA). A retrospective review of patients who underwent TAB at Spectrum Health from January 1, 1998 to December 31, 2007 was performed. Forty-seven patients, ranging in age from 25 to 87 years (mean: 70.7 years), underwent 53 TABs. Females accounted for 72.3 per cent of the subjects. Positive biopsy results showing signs of GCA were obtained in 38.3 per cent of patients. Of patients who underwent biopsy, 78 per cent could have been excluded from the procedure based upon individual diagnostic criteria. Positive and negative biopsies had average lengths of 1.84 cm and 1.29 cm, respectively (P < 0.05). In the community hospital setting, patients suspected of having GCA are frequently recommended to undergo unnecessary TAB. We advocate for more careful selection of patients to undergo this diagnostic surgical procedure. In cases where TAB is needed, we recommend a biopsy length of > 2 cm to increase the accuracy of diagnosis.