Effect of Magnetic Resonance Imaging on Acute Surgical Treatment of Pregnant Patients: A Single Institution Study.

BACKGROUND: Abdominal pathology in pregnant patients is a frequent challenge for emergency department physicians. Ultrasound is the imaging modality of choice but is inconclusive in approximately one-third of cases. Magnetic resonance imaging (MRI) is becoming increasingly available, even in acute settings. Multiple studies have defined the sensitivity and specificity of MRI in this population. OBJECTIVES: To evaluate the use of MRI findings in pregnant patients presenting with acute abdominal complaints to the emergency department. METHODS: This retrospective cohort study was conducted at a single institution. Data were collected on pregnant patients who underwent an MRI for acute abdominal complaints between 2010 and 2019 at a university center. Patient demographics, diagnosis at admission, ultrasound and MRI findings, and discharge diagnosis were recorded and evaluated. RESULTS: In total, 203 pregnant patients underwent an MRI for acute abdominal complaints during the study period. MRI was found without pathology in 138 cases (68%). In 65 cases (32%), the MRI showed findings that could explain the patient's clinical presentation. Patients presenting with long-standing abdominal pain (> 24 hours), fever, leukocytosis, or elevated C-reactive protein values were at a significantly increased risk of having an acute pathology. In 46 patients (22.6%), MRI findings changed the primary diagnosis and management while in 45 patients (22.1%) MRI findings improved characterization of the suspected pathology. CONCLUSIONS: MRI is helpful when clinical and sonographic findings are inconclusive, leading to changes in patient management in more than one-fifth of patients.

Pressure Points Technique for Traumatic Proximal Axillary Artery Hemorrhage: A Case Report.

INTRODUCTION: While the pressure points technique for proximal hemorrhage control is long known, it is not recommended in standard prehospital guidelines based on a study showing the inability to maintain occlusion for over two minutes. MAIN SYMPTOM: This report details a gunshot wound to the left axillary area with complete transection of the axillary artery, leading to profuse junctional hemorrhage and profound hemorrhagic shock. THERAPEUTIC INTERVENTION: Proximal pressure of the subclavian artery was applied against the first rib (the pressure points technique) and maintained for 28 minutes. OUTCOMES: Cessation of apparent bleeding and excellent, enduring physiologic response to blood transfusion were observed. CONCLUSION: The pressure points technique can be life-saving in junctional arterial hemorrhage and should be reconsidered in prehospital guidelines.

Mortality in relation to presence and type of oral antithrombotic agent among adult trauma patients: a single-center retrospective cohort study.

PURPOSE: Oral anticoagulants (AC) and antiplatelet (AP) agents are increasingly prescribed to prevent and treat acute and chronic thrombotic conditions. The direct oral anticoagulants (DOAC), a newer class of AC, raise concerns in the trauma setting. Our study aims to compare the mortality rates and other outcomes among adult trauma patients based on pre-admission AC/AP status. METHODS: We conducted a retrospective cohort study of a prospectively collected database of trauma patients previously on DOAC, warfarin, aspirin or clopidogrel. A matched control group of trauma patients not receiving AC/AP was used for comparison. Our primary endpoint was in-hospital mortality according to antithrombotic medication class. Secondary endpoints included length of stay (LOS), intensive care unit (ICU) admission, need for blood transfusion, and discharge to a dependent setting. Univariate and multivariate analyses were conducted. RESULTS: There were 996 exposed patients and 234 controls, with no major clinically significant difference among study groups in terms of gender, injury site, injury severity, mechanism, and comorbidities. The mortality rates were 2.14% (control, 5/234), 2.88% (DOAC, 3/104), 3.34% (aspirin, 17/509), 7.63% (warfarin, 18/236), 9% (clopidogrel, 8/89), and 13.79% (aspirin + clopidogrel, 8/58) (p < 0.001). In multivariate analyses, there was no difference regarding mortality between DOAC and reference groups. Blood transfusion was more likely in patients receiving warfarin or AP than those prescribed DOAC. CONCLUSION: There was no evidence of increased mortality or blood transfusion requirement among trauma patients on DOAC, including head trauma patients. Further studies on head trauma and specific subgroups of DOAC are recommended.

Novel self-fixation chest drain device tested in a swine model of pneumo-hemothorax.

INTRODUCTION: Thoracic injuries account for 20-25% of trauma-related deaths. In cases of pneumothorax the insertion of a chest tube is mandatory but associated with high complication rates particularly when inserted under difficult conditions. The C-Lant is a novel chest-tube insertion device that provides integrated double fixation capabilities and can be used by responders with minimal experience. The aim of the study was to test the device in a large animal model. MATERIAL AND METHODS: Pneumothorax, tension pneumothorax, and hemothorax were induced in four white domestic female pigs. The C-Lant device (Vigor Medical Technologies, Haifa, Israel) was inserted as any chest-drain to decompress the thorax. Pull test was applied to test the strength of device fixation. RESULTS: The insertion of the device was simple and effective without detectable negative physiological effects. Reliable fixation was achieved without difficulty. Air and liquid were promptly drained from the chest cavity. Minimal tissue laceration occurred when applying the device in a scenario of erroneous pneumothorax diagnosis with fully expanded lungs. Interconnection with other surgical accessories was smooth. CONCLUSION: The C-Lant is a novel device that facilitates easy insertion and fixation of chest-tubes by minimally experienced medical providers and reduces the likelihood of unwanted expulsion. Clinical studies are planned.

Multi-port versus single-port cholecystectomy: results of a multi-centre, randomised controlled trial (MUSIC trial).

BACKGROUND: Single-port laparoscopic surgery as an alternative to conventional laparoscopic cholecystectomy for benign disease has not yet been accepted as a standard procedure. The aim of the multi-port versus single-port cholecystectomy trial was to compare morbidity rates after single-access (SPC) and standard laparoscopy (MPC). METHODS: This non-inferiority phase 3 trial was conducted at 20 hospital surgical departments in six countries. At each centre, patients were randomly assigned to undergo either SPC or MPC. The primary outcome was overall morbidity within 60 days after surgery. Analysis was by intention to treat. The study was registered with ClinicalTrials.gov (NCT01104727). RESULTS: The study was conducted between April 2011 and May 2015. A total of 600 patients were randomly assigned to receive either SPC (n = 297) or MPC (n = 303) and were eligible for data analysis. Postsurgical complications within 60 days were recorded in 13 patients (4.7 %) in the SPC group and in 16 (6.1 %) in the MPC group (P = 0.468); however, single-access procedures took longer [70 min (range 25-265) vs. 55 min (range 22-185); P < 0.001]. There were no significant differences in hospital length of stay or pain VAS scores between the two groups. An incisional hernia developed within 1 year in six patients in the SPC group and in three in the MPC group (P = 0.331). Patients were more satisfied with aesthetic results after SPC, whereas surgeons rated the aesthetic results higher after MPC. No difference in quality of life scores, as measured by the gastrointestinal quality of life index at 60 days after surgery, was observed between the two groups. CONCLUSIONS: In selected patients undergoing cholecystectomy for benign gallbladder disease, SPC is non-inferior to MPC in terms of safety but it entails a longer operative time. Possible concerns about a higher risk of incisional hernia following SPC do not appear to be justified. Patient satisfaction with aesthetic results was greater after SPC than after MPC.

When a vehicle becomes a weapon: intentional vehicular assaults in Israel.

BACKGROUND: We have recently witnessed an epidemic of intentional vehicular assaults (IVA) aimed at pedestrians. We hypothesized that IVA are associated with a specific injury pattern and severity. METHODS: Retrospective analysis of prospectively acquired data of patients injured following IVA from October 2008 to May 2016 who were admitted to the Hadassah Level I trauma center in Jerusalem, Israel. Comparison of injury parameters and outcome caused by vehicular attacks to non-intentional pedestrian trauma (PT). Measured outcomes included ISS, AIS, injury pattern, ICU and blood requirements, participating teams, length of stay, and mortality. RESULTS: There were 26 patients in the IVA group. Mean age in the IVA group was significantly younger and there were more males compared to the PT group (24.7 ± 13.3 years vs. 48.3 ± 21.3, and 81% vs. 52%, respectively, p < 0.01). Lower extremity (77% of patients), followed by head (58%) and facial (54%) injuries were most commonly injured in the IVA group, and this was significantly different from the pattern of injury in the PT group (54, 35, and 28%, respectively, p < 0.05). Mean ISS and median head AIS were significantly higher in the IVA group compared with the PT group (23.2 ± 12.8 vs. 15.4 ± 13.8, p = 0.012, and 4.5 vs. 3, p = 0.003, respectively). ICU admission and blood requirement were significantly higher in the IVA group (69% vs. 38%, and 50% vs. 19%, p < 0.01). Mortality was significantly higher in the IVA group (4 patients, 15%, vs. 3 patients, 4%, respectively, p = 0.036) and was caused by severe head trauma in all cases. DISCUSSION: The severity of injury and mortality rate following IVA are higher compared with pedestrian injury. The pattern of injury following IVA is significantly different from non-intentional pedestrian trauma. CONCLUSIONS: IVA results in higher mortality than conventional pedestrian trauma secondary to more severe head injury. More hospital resources are required following IVA than following conventional road traffic accidents.

Reusable single-port access device shortens operative time and reduces operative costs.

BACKGROUND: In recent years, single-port laparoscopy (SPL) has become an attractive approach for performing surgical procedures. The pitfalls of this approach are technical and financial. Financial concerns are due to the increased cost of dedicated devices and prolonged operating room time. Our aim was to calculate the cost of SPL using a reusable port and instruments in order to evaluate the cost difference between this approach to SPL using the available disposable ports and standard laparoscopy. METHODS: We performed 22 laparoscopic procedures via the SPL approach using a reusable single-port access system and reusable laparoscopic instruments. These included 17 cholecystectomies and five other procedures. Operative time, postoperative length of stay (LOS) and complications were prospectively recorded and were compared with similar data from our SPL database. Student's t test was used for statistical analysis. RESULTS: SPL was successfully performed in all cases. Mean operative time for cholecystectomy was 72 min (range 40-116). Postoperative LOS was not changed from our standard protocols and was 1.1 days for cholecystectomy. The postoperative course was within normal limits for all patients and perioperative morbidity was recorded. Both operative time and length of hospital stay were shorter for the 17 patients who underwent cholecystectomy using a reusable port than for the matched previous 17 SPL cholecystectomies we performed (p < 0.001). Prices of disposable SPL instruments and multiport access devices as well as extraction bags from different manufacturers were used to calculate the cost difference. Operating with a reusable port ended up with an average cost savings of US$388 compared with using disposable ports, and US$240 compared with standard laparoscopy. CONCLUSION: Single-port laparoscopic surgery is a technically challenging and expensive surgical approach. Financial concerns among others have been advocated against this approach; however, we demonstrate herein that using a reusable port and instruments reduces operative time and overall operative costs, even beyond the cost of standard laparoscopy.

A novel totally internal laparoscopic liver retractor.

INTRODUCTION: Minimally invasive surgery is still in evolution. Throughout the past two decades numerous devices have been developed to enable safer and faster procedures, including anastomosis creating devices, energy sources, and superior imaging. However, retraction capabilities were put aside and currently, organ laparoscopic retraction is based on standard laparoscopic tools. In the era of minimizing the number of ports and shrinking their size, our aim was to develop internal retraction device that could be placed in the peritoneal cavity through a standard trocar, positioned for adequate retraction, and left in place for the entire procedure. These devices would obviate the need for inserting ports dedicated for retraction only and hence contribute to the reduction of the number of incisions. Herein, we present our initial experience with a novel internal liver retractor. MATERIALS AND METHODS: The Endolift retractor is a simple telescopic rod that has anchoring claws at each end. It can be inserted using 5 mm standard trocar using a dedicated applier and anchored to the peritoneum beside the liver edges thereby lifting the undersurface of the liver and exposing the organs underneath. To achieve retraction of the left lateral segment, the Endolift retractor is anchored lateral to the right diaphragmatic crus on 1 side and lateral to the falciform ligament on the other. RESULTS: A total of 14 operations were performed using the Endolift retractor for liver retraction including antireflux procedure, robotic-assisted Heller's myotomy, bariatric procedures, and bile duct exploration. The left lobe of the liver was adequately retracted and enabled access to the operating field. Repositioning was easily performed with progression of the surgery when necessary. CONCLUSIONS: Internal retraction devices such as the Endolift retractor for liver retraction are one step further in minimizing trauma to the abdominal wall during minimal invasive surgery. It obviates the need for extra incisions, frees up the surgeons' hands, and may enable performing complicated laparo-endoscopic single-site laparoscopy and natural orifice transluminal endoscopic surgery.

Early outcome after laparoscopic sleeve gastrectomy of type two diabetes mellitus patients with extremely elevated glycated hemoglobin (HbA1c).

BACKGROUND: Due to high prevalence of type 2 diabetes mellitus (T2DM) and increasing popularity of bariatric and metabolic operations, Surgeons are faced with patients with relatively more severe T2DM disease. High level of glycated hemoglobin (HbA1c) is widely considered as a marker for uncontrolled T2DM. The aim of this study was to explore the correlation between high level of pre-operative HbA1c, peri-operative morbidity and post operative outcome after laparoscopic sleeve gastrectomy. METHODS: We conducted a retrospective study based on our medical center metabolic and bariatric registry. The inclusion criteria for selecting patients to the study group was HbA1c of 9 gram/dL and higher. A comparison control study was designed to include T2DM patients similar in all characteristics except for HbA1c of 7.5 gram/dl and less. RESULTS: We included 20 patients who underwent laparoscopic sleeve gastrectomy. Each group of patients included half of the patients. The mean pre operative HbA1c in the studied and the control group were 10.4 gram/dL and 7.1 gram/dL respectively (p<0.001). There were no differences in peri-operative morbidity and length of stay at the hospital. Mean excess weight loss, fasting glucose levels and HbA1c levels were similar six months post surgery mean. CONCLUSIONS: According to our study we have not found correlation between high HbA1c levels and increased peri-operative morbidity or insufficient excess weight loss among patients who underwent laparoscopic sleeve gastrectomy.

Comparing laparoscopic mesh fixation strength between articulated and non-articulated tack devices.

AIM: The iMESH Tacker™ (IMT) device is a device which simplifies laproscopic hernia repair by enabling an articulation of the device tip. The study compares the strength of mesh fixation between the IMT and another commercial tack (ACT) device - Absorbatack™ (Covidien, Corp, Mansfield, MA, USA). MATERIAL AND METHODS: Strips of mesh were installed on the abodminal wall of three pigs. Half of the meshes were fixated by IMT and half by ACT. Euthanasia was done immediately to the first pig, after14 days to the second and after 27 days to the third pig. The mesh strips were pulled while fixation force was measured. Statistical analysis was done using the two tailed t-test. All mesh strips were found to be fixated. Through detachment force test, the average force in the first pig was 17.1N ± 1.9 and 16.5N ± 8.3 (IMT and ACT respectively, n/s). The average force in the second pig was 18.8N ± 7.3 and 8.4N ± 4.1 (IMT and ACT respectively, p < 0.05). The average force in the third pig was 16.3N ± 5.3 and 10.9N ± 5.9 (IMT and ACT respectively, p < 0.05). CONCLUSION: The use of IMT is both feasible and easy to learn. The study showed that IMT creates average fixation force which is higher than ACT.