Effect of Body Mass Index on Outcomes After Surgery for Perforated Diverticulitis.

BACKGROUND: Despite the increased adoption of minimally invasive techniques in colorectal surgery, an open resection with ostomy creation remains an accepted operation for perforated diverticulitis. In the United States, there is an increase in the rates of both morbid obesity and diverticular disease. Therefore, we wanted to explore whether outcomes for morbidly obese patients with diverticulitis are worse than nonmorbidly obese patients after open colectomy for diverticulitis. MATERIALS AND METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2015, we identified adults with emergent admission for diverticulitis (International Classification of Diseases, Ninth Revision, code 562.11) with evidence of preoperative sepsis and intraoperative contaminated/dirty wound classification, in which a resection with ostomy (Current Procedural Terminology codes 44141, 44143, or 44144) was performed. We excluded cases with age >90 y, ventilator dependence, evidence of disseminated cancer and missing sex, race, body mass index, functional status, American Society of Anesthesiologists class, length of stay (LOS), or operative time data. Morbid obesity was defined as body mass index >35 kg/m2. Risk variables of interest included age, sex, race, medical comorbidities, requirement for preoperative transfusion, preoperative sepsis, and operative time. Outcomes of interest included LOS, 30-d postoperative complications, and mortality. Univariate and propensity scores with postmatching analyses were performed. RESULTS: A total of 2019 patients met inclusion and exclusion criteria, of which 413 (20.5%) were morbidly obese. Morbidly obese patients tended to be younger (mean 57.2 versus 62.6 y) and female (54.5% versus 45.5%). Morbidly obese patients also had higher rates of insulin-dependent diabetes (8.0% versus 4.2%), hypertension (60.1% versus 51.3%), renal failure (3.4% versus 1.5%), and higher American Society of Anesthesiologists class (class 4: 23.5% versus 19.6% and class 5: 1.45% versus 0.87%). Morbidly obese patient had no increase in 30-d mortality or LOS, but they had higher rates of superficial wound infection (9.0% versus 5.8%; P = 0.0259), deep wound infection (4.4% versus 1.9%; P = 0.0073), acute renal failure (4.8% versus 2.4%; P = 0.0189), postoperative septic shock (17.7% versus 12.1%; P = 0.0040), and return to the operating room (11.1% versus 6.4%; P = 0.0015). We identified 397 morbidly obese patients well matched by propensity score to 397 nonmorbidly obese patients. Conditional logistic regression showed no difference in LOS (median 12.9 versus 12.4 d; P = 0.4648) and no increased risk of 30-d mortality (P = 0.947), but morbid obesity was an independent predictor for return to the operating room (adjusted odds ratio: 27.09 [95% confidence interval: 2.68-274.20]; P = 0.005). CONCLUSIONS: This analysis of a large national clinical database demonstrates that morbidly obese patients presenting with perforated diverticulitis undergoing a Hartmann's procedure do not have increased mortality or LOS compared with nonobese patients. After adjusting for the effects of morbid obesity, morbidly obese patients had increased risk of return to operating room. Despite literature describing the many perioperative risks of obesity, our analysis showed only increased reoperation for obese patients with diverticulitis.

Can the Laparoscopic Approach for Adhesive Small Bowel Obstruction be Used in Octogenarians? An Observational Study Using ACS NSQIP.

BACKGROUND: With the population of octogenarians projected to increase fourfold by 2050, we sought to compare outcomes of laparoscopic versus open approach in octogenarians requiring surgery for adhesive small bowel obstruction (SBO). METHODS/MATERIALS AND METHODS: Using 2006-2015 American College of Surgeons National Surgical Quality Improvement Project, we identified patients aged ≥80 y who underwent emergency surgery within 1 d of admission for SBO. Risk variables of interest included age, sex, race, body mass index, preoperative sepsis, and American Society of Anesthesiologists (ASA) classification. Outcomes included length of stay, mortality, and pneumonia. Univariable and multivariable analyses were performed. RESULTS: Eight hundred fifty-six patients were identified. Six hundred ninety-nine (81.7%) underwent laparotomy; 157 (18.3%) underwent laparoscopy. Twenty-four (15.3%) of laparoscopic cases were converted. There was no difference between the open and laparoscopic groups in age, and race, preoperative albumin, or preoperative sepsis. The open group had higher rates of totally dependent functional status, congestive heart failure, chronic obstructive pulmonary disease, and higher ASA class. There was no difference in operative time. Laparoscopy was associated with shorter length of stay. The open approach showed higher rates of postoperative pneumonia, myocardial infarct, and mortality. Multivariable analysis showed increased age, functional status, preoperative albumin, and ASA class associated with mortality. The operative approach was not associated with mortality. Postoperative pneumonia was associated with male sex and open approach. CONCLUSIONS: Age, preoperative functional status, low preoperative albumin, and ASA classes IV and V were associated with mortality, while the open approach and male sex were associated with postoperative pneumonia. Octogenarians who present with SBO due to adhesive disease may benefit from an initial laparoscopic exploration. Further prospective studies are warranted.

Systemic Determinants in Surgery: Nonclinical Factors Affecting Time to Operation for Incarcerated Ventral Hernias.

INTRODUCTION: We explore nonclinical factors affecting the amount of time from admission to the operating room for patients requiring nonelective repair of ventral hernias. METHODS: Using the 2005-2012 Nationwide Inpatient Sample, we identified adult patients with a primary diagnosis of ventral hernia without obstruction/gangrene, who underwent nonelective repair. The outcome variable of interest was time from admission to surgery. We performed univariate and multivariable analyses using negative binomial regression, adjusting for age, sex, race, income, insurance, admission day, comorbidity status (van Walraven score), diagnosis, procedure, hospital size, location/teaching status, and region. RESULTS: 7,253 patients met criteria, of which majority were women (n = 4,615) and white (n = 5,394). The majority of patients had private insurance (n = 3,015) followed by Medicare (n = 2,737). Median time to operation was 0 days. Univariate analysis comparing operation <1 day to ≥1 day identified significant differences in race, day of admission, insurance, length of stay, comorbidity status, hospital location, type, and size. Negative binomial regression showed that weekday admission (IRR 4.42, P < .0001), private insurance (IRR 1.53-2.66, P < .0001), rural location (IRR 1.39-1.76, P < .01), small hospital size (IRR 1.26-1.36, P < .05), white race (IRR 1.30-1.34, P < .01), healthier patients (van Walraven score IRR 1.05, P < .0001), and use of mesh (IRR 0.39-0.56, P < .02) were associated with shorter time until procedure. CONCLUSION: Shorter time from admission to the operating room was associated with several nonclinical factors, which suggest disparities may exist. Further prospective studies are warranted to elucidate these disparities affecting patient care.

Does Operative Time Affect Complication Rate in Laparoscopic Cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is the most common laparoscopic procedure performed in the United States. Our aim was to determine if increased operative time (OT) is associated with increased morbidity following laparoscopic cholecystectomy. METHODS: Using ACS NSQIP from 2006 to 2015, we identified all adult (≥18 years) patients that underwent laparoscopic cholecystectomy for cholecystitis performed within 3 days of admission. Our analysis was limited to cases with OT ≥15 minutes and ≤360 minutes. Outcome variables included postoperative surgical site infections (SSI), dehiscence, pneumonia, reintubation, failure to wean from ventilator, pulmonary embolism, renal failure, urinary tract infection, cardiac arrest, myocardial infarct, bleeding, deep vein thrombosis, sepsis, septic shock, return to the operating room, and death. RESULTS: 7,031 cases met inclusion criteria. Median OT was 63 minutes, first quartile was 46 minutes and third quartile was 87 minutes. Logistic regression analysis showed that increased OT (third vs first quartile) was an independent risk factor for superficial SSI (OR 1.75, 95% CI 1.36-2.25, P < .0001), organ-space SSI (OR 1.77, 95% CI 1.33-2.35, P < .0001), dehiscence (OR 2.03, 95% CI 1.01-4.07, P = 0.0470), and septic shock (OR 1.81, 95% CI 1.06-3.09, P = 0.0286). Increased OT was independently associated with increased LOS (fourth vs 1st quartile: IRR 1.53, P < 0.0001; third vs 1st quartile: IRR 1.29, P < .0001; 2nd vs 1st quartile: IRR 1.16, P < 0.0001). CONCLUSION: Increased OT is independently associated with morbidity and increased LOS following laparoscopic cholecystectomy for cholecystitis. Prospective studies are warranted to determine which factors contribute to increased OT and why.

The Full Continuum of Robotic Breast Surgery: Robotic-assisted Mastectomy, Robotic DIEP Flap, and Robotic Supermicrosurgery.

In recent years, robotic surgery has rapidly expanded to improve surgical outcomes in a variety of surgical subspecialties. Although plastic surgery has taken longer to integrate robotic surgery into practice, the advantages of robotic-assisted surgery, including improved visualization and resolution, minimally invasive approaches, and the ability to surpass human precision and scale, have driven its more recent adoption into plastic surgery. Currently, procedures performed with robotic assistance that are considered part of the continuum of surgical treatment of breast cancer include robotic-assisted nipple-sparing mastectomy, reconstruction with the robotic latissimus dorsi flap or the deep inferior epigastric artery perforator flap, and robotic microsurgery for the flap anastomosis and/or the surgical treatment of lymphedema. The authors provide an overview of robotic surgery and how it has been integrated into the field of plastic surgery, as well as a review of the most common procedures within the field where robotic assistance can be incorporated: nipple-sparing mastectomy, robotic latissimus flap, robotic deep inferior epigastric artery perforator flap breast reconstruction, and microvascular anastomoses.

Laparoscopic Ventral Hernia Repair Postoperative Complications in End Stage Renal Disease Patients.

Background: The prevalence of patients with end stage renal disease (ESRD) requiring general surgical procedures is increasing. Our aim was to explore the effect of ESRD on patients undergoing elective laparoscopic ventral hernia repair. Methods: The American College of Surgeons National Surgical Quality Improvement Program (2010-2015) database was used to identify patients who underwent elective laparoscopic ventral hernia repair. Multivariable analysis was performed adjusting for risk variables including age, gender, race, comorbidity status, body mass index ≥ 35, and presence of ESRD. Results: A total of 8,789 patients undergoing elective laparoscopic ventral hernia repair were identified. Sixty-four patients (0.73%) had ESRD. ESRD was identified as an independent risk factor for postoperative pneumonia (odds ration [OR] 6.91, p = 0.00363), sepsis (OR 18.58, p = 0.000286), and length of stay (IRR 1.63, 95% confidence interval 1.19 - 2.27, p = 0.0036). Conclusions: ESRD patients undergoing elective laparoscopic ventral hernia repair had an increased risk of postoperative pneumonia, sepsis, and length of stay. Clinicians should be cognizant of these risks when performing elective operations on ESRD patients.

Facility of Origin Predicts Mortality After Colonic Perforation.

INTRODUCTION: Colonic perforation often requires emergent intervention and carries high morbidity and mortality. The objective of this study was to determine whether nonclinical factors, such as transition of care from outpatient facilities to inpatient settings, are associated with increased risk of mortality in patients who underwent emergent surgical intervention for colonic perforation. MATERIALS AND METHODS: Using the 2006-2015 ACS National Surgical Quality Improvement Program database, we identified adult patients who underwent emergent partial colectomy with primary anastomosis ± protecting ostomy or partial colectomy with ostomy with intraoperative finding of wound class III or IV for a diagnosis of perforated viscus. The outcome of interest was 30-day postoperative mortality. Univariate and multivariate analyses using logistic regression were performed. RESULTS: 4705 patients met criteria, of which 841 (17.9%) died. Univariate analysis showed that patients who died after emergent surgery for perforated viscus were more likely to present from a chronic care facility (13.4% vs. 4.4%, P < .0001) and had longer time from admission to undergoing surgery (mean 4.1 vs. 2.0 days, P < .0001. Logistic regression demonstrated that septic shock vs. none (OR 3.60, P < .0001), sepsis vs. none (OR 1.57, P = .00045), transfer from chronic care facility vs. home (OR 1.87, P < .0001), and increased time from admission vs. operation (OR 1.01, P = .0055) were independently associated with increased risk of death. DISCUSSION: Transfer from a chronic care facility was independently associated with increased mortality in patients undergoing emergent surgery for perforated viscus.

Comparing Surgical Outcomes Among Patients Admitted for Small Bowel Obstruction on Weekend vs. Weekday.

INTRODUCTION: Surgical intervention is important in reducing morbidity and mortality among patients admitted for small bowel obstruction (SBO). Patient-specific variables such as age and comorbidities are risk factors for adverse outcomes after surgery for SBO. However, the effect of weekend admission on outcomes has not been well delineated in the literature. Our aim was to determine whether weekend admission affects mortality and length of stay (LOS) in patients who were admitted for SBO and were managed operatively. MATERIALS AND METHODS: Using the 2006-2012 Nationwide Inpatient Sample (NIS) database, we identified adult patients who were admitted with a primary diagnosis of SBO and had a primary procedure of exploratory laparotomy, lysis of adhesions, or small bowel resection. We performed univariate analysis comparing cases that were admitted on the weekend vs. weekday. We then performed negative binomial regression with LOS as the dependent variable, adjusting for risk variables. RESULTS: 2804 patients were studied, of which 728 (26.0%) were admitted on the weekend. Univariate analysis showed no statistically significant difference in mortality or LOS for patients admitted on a weekday vs. weekend. Multivariate analysis showed that several factors were associated with increased LOS, including third quartile van Walraven score (P < .0001) and large hospital size (P = .0031). Other factors were associated with decreased LOS, including fourth quartile of income (P = .0022) and weekend admission (P = .048). DISCUSSION: There is no significant difference in mortality between patients admitted on weekend vs. weekday for SBO, but patients admitted on weekend are more likely to have a decreased LOS.

End Stage Renal Disease Is Associated with Increased Mortality in Perforated Gastroduodenal Ulcers.

Patients with end stage renal disease (ESRD) represent a growing subset of surgical candidates and ESRD status has been associated with increased morbidity and mortality in other operations. Using a national database, we examined outcomes and risk factors for patients presenting with perforated gastroduodenal ulcers undergoing omentopexy. We identified adult and emergent patients with perforated duodenal and gastroduodenal ulcers that underwent omentopexy using the 2005 to 2012 Nationwide Inpatient Sample. We identified patients with ESRD status and assessed comorbidity status using the Elixhauser-van Walraven score. Univariate and multivariable logistic regression analyses were performed. Inpatient mortality was the primary outcome. Six thousand five hundred and twenty-one patients were identified. Median age was 59.0 years, majority were male (55.56%), 79 (1.21%) patients had ESRD, 367 (5.63%) patients died during admission. Multivariable logistic regression showed age (OR 2.71, P < 0.0001), Elixhauser-van Walraven score (OR 2.69, P < 0.0001), and ESRD status (OR 3.88, P < 0.0001) as independent risk factors for mortality. ESRD was associated with increased mortality in patients undergoing omentopexy for perforated gastroduodenal ulcers. Future studies are necessary to identify methods to increase perioperative survival.

Robotic TAPP Ventral Hernia Repair: Early Lessons Learned at an Inner City Safety Net Hospital.

BACKGROUND AND OBJECTIVES: Ventral hernia repair is one of the most commonly performed general surgery procedures, and minimally invasive approaches are increasingly preferred. The physiologic repair offered by the preperitoneal approach is favorable, with reduced complications, but it remains a technical challenge. The robotic platform allows for enhanced instrument flexibility and ease of operation. We conducted a retrospective review of our experience with robotic transabdominal preperitoneal repair (rTAPP) versus robotic intraperitoneal onlay mesh (rIPOM) at a tertiary care hospital in an urban setting. METHODS: We reviewed the records of patients undergoing minimally invasive ventral hernia repair from March 2014 through March 2017. Demographics, complication rates, and operative time were compared by t test and Chi square test, as applicable. RESULTS: Sixty-three patients met the criteria for inclusion in the study. Of those, 27 underwent ventral hernia repair with rIPOM and 36 with rTAPP, with no major intraoperative complications. There were no significant differences in demographics between the 2 groups in age, BMI, and sex. The difference in mean operative time was not significant (rIPOM 167.26 [SD 51.76] minutes vs rTAPP 158.84 minutes [SD 61.5]; P = .57), whereas mean console time was significantly different (rIPOM 70.88 minutes [SD 32.88] vs rTAPP 90.26 [SD 31.17]; P = .018). Postoperative complications occurred only with rIPOM and included urinary retention, seroma, and fever. CONCLUSIONS: rTAPP is a promising alternative to rIPOM, with reduced complications without adding significant operative time, and may allow for reduced costs.

A Calculated Risk: Performing Laparoscopic Cholecystectomy for Acute Cholecystitis on Patients with End Stage Renal Disease.

End-stage renal disease (ESRD) is a multifactorial disease linked to socioeconomic status and associated with worse surgical outcomes. We explore intraoperative and postoperative outcomes in patients with cholecystitis undergoing laparoscopic cholecystectomy (LC). The Nationwide Inpatient Sample from 2005 to 2012 was used to identify patients undergoing LC for cholecystitis using ICD-9 codes. Outcomes of interest were mortality, common bile duct injury, conversion to open, intraoperative complications, postoperative complications, length of stay (LOS), and total charge. Univariate analysis was performed using t test for continuous variables and chi-squared test for categorical variables. Multivariable models were created that adjusted for age, demographics, year of admission, comorbidities, and presence of ESRD. Of 225,058 patients that underwent LC, 2,115 had ESRD. On univariate analysis, the ESRD cohort had a higher incidence of mortality and complications: intraoperative, mechanical wound, respiratory, cardiovascular, and postoperative infections. ESRD patients had higher median LOS and total charge. Multivariate analysis showed ESRD as an independent risk factor for mortality, mechanical wound complications, and intraoperative complications. Negative binomial regression analysis showed that ESRD patients had LOS 50.4 per cent longer than non-ESRD patients. Linear regression analysis showed that, after adjustment, ESRD patients had total charge 6.82 per cent higher than non-ESRD patients. In this large retrospective analysis, we find that after adjusting for clinical, socioeconomic, and demographic variables, ESRD is an independent risk factor for increased mortality, intraoperative complications, mechanical wound complications, increased LOS, and cost for patients undergoing LC. Prospective studies exploring risk optimization strategies for patients with ESRD are warranted.

The utilization of fluorescent cholangiography during robotic cholecystectomy at an inner-city academic medical center.

In recent years, fluorescent cholangiography using Indocyanine green (ICG) dye has been used to aid identification of structures during robotic cholecystectomy. We sought to compare cholecystectomy with ICG dye versus laparoscopic cholecystectomy at an inner-city academic medical center. Between January 2013 and July 2016, we identified 287 patients of which 191 patients underwent laparoscopic cholecystectomy and 96 patients underwent robotic cholecystectomy with ICG dye. Preoperative risk variables of interest included age, sex, race, body mass index (BMI), and acute cholecystitis. Primary outcome of interest was conversion to open procedures while secondary outcome was length of stay. The two groups were similar in their BMI (31.98 vs. 31.10 kg/m2 for the laparoscopic and robotic, respectively, p = 0.32). The laparoscopic group had a greater mean age compared to the robotic group (47.77 vs. 43.61 years, p = 0.04). There was no significant difference in sex and emergency surgery between the two groups. Fewer open conversions were found in the robotic than the laparoscopic group [2 (2.1%) vs. 17 (8.9%), p = 0.03]. In multiple logistic regression, robotic cholecystectomy with ICG also showed a lower risk of conversion compared to laparoscopic cholecystectomy, but the difference did not reach statistical significance (OR 0.42, 95% CI 0.11-1.65, p = 0.22). ICG fluorescent cholangiography during robotic cholecystectomy may contribute to proper identification of biliary structures and may reduce the rates of open conversion. The preliminary results of fewer open conversions are promising. Further studies with a large randomized prospective controlled study should be taken for further evaluation.

Mortality in patients with end-stage renal disease and the risk of returning to the operating room after common General Surgery procedures.

BACKGROUND: The prevalence of end-stage renal disease (ESRD) has increased, and there is limited data on the risks faced by this patient population undergoing surgery. METHODS: Using American College of Surgeons National Surgical Quality Improvement Program, we identified common surgical procedures undergone by patients with ESRD. These patients were compared with a matched-control group. A subanalysis was performed to determine the risk factors for returning to the operating room in patients with ESRD. RESULTS: Of the 195,585 patients identified, 1,163 had ESRD. ESRD was associated with increased mortality (odds ratio [OR] 9.05, confidence interval [CI] 4.09 to 20.00) and rates of return to the operating room (OR 2.97, CI 1.99 to 4.46). Returning to the OR was associated with increased operation times (98.9 vs 130.2 minutes, P < .05), mortality (OR 4.35, CI 2.11 to 8.99), and morbidity (OR 7.6, CI 4.68 to 12.41). CONCLUSIONS: Patients with ESRD face greater risks when entering the operating room, and further study is needed to elucidate preventable risk factors.

Appendectomy in patients with human immunodeficiency virus: Not as bad as we once thought.

BACKGROUND: The number of patients living with human immunodeficiency virus and acquired immunodeficiency syndrome is growing due to advances in antiretroviral therapy. Existing literature on appendectomy within this patient population has been limited by small sample sizes. Therefore, we used a large, multiyear, nationwide database to study this topic comprehensively. METHODS: Using the Nationwide Inpatient Sample, we identified 338,805 patients between 2005 and 2012 who underwent laparoscopic or open appendectomy for acute appendicitis. Interval appendectomies were excluded. We used multivariable adjusted regression models to test differences between patients with human immunodeficiency virus without acquired immunodeficiency syndrome and a reference group, as well as human immunodeficiency virus with acquired immunodeficiency syndrome and a reference group, with regard to duration of stay, hospital charges, in-hospital complications, and in-hospital mortality. Models were adjusted for patient age, sex, race, insurance, socioeconomic status, Elixhauser comorbidity score, and appendix perforation. RESULTS: There were 1,291 (0.38%) patients with human immunodeficiency virus, among which 497 (0.15%) patients had acquired immunodeficiency syndrome. In regression analysis, human immunodeficiency virus alone was not associated with adverse outcomes, while acquired immunodeficiency syndrome alone was associated with longer duration of stay (incidence rate ratio 1.40 [1.37-1.57 95% confidence interval], P < .0001), increased total charges (exponentiated coefficient 1.16 [1.10-1.23 95% confidence interval], P < .0001), and increased risk of postoperative infection (odds ratio 2.12 [1.44-3.13 95% confidence interval], P = .0002). CONCLUSION: Patients with acquired immunodeficiency syndrome who undergo appendectomy for acute appendicitis are subject to longer and more expensive hospital admissions and have greater rates of postoperative infections while patients with human immunodeficiency virus alone are not at risk for adverse outcomes.

Robot-Assisted Transabdominal Preperitoneal Ventral Hernia Repair.

BACKGROUND AND OBJECTIVES: We believe that complications due to the mesh used in ventral hernia repairs can be reduced by using the natural barrier afforded by the peritoneum. This can be challenging to do laparoscopically, however we felt that the robot-assisted laparoscopic approach reduces the difficulty in placing the mesh in the preperitoneal space, and we want to share our early experiences with this approach. We describe the surgical technique used in robot-assisted laparoscopic transabdominal preperitoneal (TAPP) ventral hernia repair with mesh. In addition, we evaluate its feasibility and present preliminary perioperative results. METHODS: We performed robot-assisted laparoscopic TAPP ventral hernia repairs in 3 patients in the spring of 2015. Demographic information and defect size were measured. Conversion from a laparoscopic to an open procedure was the primary outcome variable. RESULTS: There were 3 cases of robot-assisted TAPP ventral hernia repair with mesh. The mean age of the patients was 49 years, the mean body mass index was 32.6 kg/m(2), and the mean operative time was 163.7 minutes. The mean defect size was 1219.0 mm(2). There were no conversions to open during this early learning phase. All patients were discharged home within the 24-hour postoperative period. No complications were noted during a mean follow-up of 3 months. CONCLUSIONS: We present our early experience with robot-assisted TAPP ventral hernia repair. We note that because of improved ergonomics and wristed instrumentation, the robotic platform enabled creation of peritoneal flaps and complete coverage of mesh with peritoneum after primary closure of the defect. The robotic approach is feasible and may provide a better environment for mesh integration and protection. Further investigations with long-term follow-up are needed to verify that this technique is effective in reducing mesh-related intra-abdominal complications.

A rare case of splenic pseudoaneurysm in pediatric splenic blunt trauma patient: Review of diagnosis and management.

INTRODUCTION: Splenic pseudoaneurysms (SPA) are a rare but serious sequela of blunt traumatic injury to the spleen. Management of adult blunt splenic trauma is well-studied, however, in children, the management is much less well-defined. PRESENTATION OF CASE: A 15 year-old male presented with severe abdominal pain of acute onset after sustaining injury to his left side while playing football. FAST was positive for free fluid in the abdomen. Initial abdomen CT demonstrated a grade III/IV left splenic laceration with moderate to large hemoperitoneum with no active extravasation or injury to the splenic vessels noted. A follow-up CT angiography of the abdomen demonstrated a splenic hypervascular structure suspicious for a small pseudoaneurysm. Splenic arteriogram which demonstrated multiple pseudoaneurysms arising from the second order splenic artery branches which was angioembolized and treated. DISCUSSION & CONCLUSION: Questions still remain regarding the timing of repeat imaging for diagnosis of SPA following non-operative blunt splenic trauma, which patients should be imaged, and how to manage SPA upon diagnosis. More clinical study and basic science research is warranted to study the disease process of SPA in pediatric patient. We believe that our proposed management algorithm timely detect formation of delayed SPA formation and addresses the possible fatal disease course of pediatric SPA.

A case of isolated splenic tuberculosis.

There are few cases of isolated splenic tuberculosis reported in the literature internationally, and nearly none from western medical centers. The incidence of tuberculosis has declined in the United States since the 1950s, with 11,585 reported cases in 2009, 21% of which were exclusively extrapulmonary. Splenic tuberculosis occurs mostly as part of miliary tuberculosis in immunocompromised patients. Isolated splenic tuberculosis is extremely rare, particularly in the immunocompetent patient. Patients susceptible to acquiring splenic tuberculosis usually have one of the following risk factors: immunosuppression, preceding pyogenic infections, splenic abnormalities, prior trauma to the spleen, sickle cell disease and other hemopathies, and in the immunocompetent patient another body site infected by M. tuberculosis. In this report we present the case of a young immunocompetent male with no other significant past medical history with isolated splenic tuberculosis.

Single-Site Robotic Cholecystectomy at an Inner-City Academic Center.

INTRODUCTION: We investigate the safety and efficacy of single-site robotic cholecystectomy compared to laparoscopic cholecystectomy at an inner-city academic medical center. MATERIALS AND METHODS: Retrospective analysis comparing single-site robotic to laparoscopic cholecystectomies from August 1, 2013, to January 31, 2015, was conducted. Age, gender, race, body mass index (BMI), total operative time (docking and console time for robotic cases), length of stay, comorbidities, and conversion to open procedures were examined. The χ(2) and Student's t test were used for categorical and continuous data, respectively. A P ≤ 0.05 was considered statistically significant. RESULTS: From August 2013 to January 2015, 70 single-site robotic cholecystectomies and 70 laparoscopic cholecystectomies were performed. Patients were older (mean age, 40.3 years vs 47.6 years; P = .0084), had a higher mean BMI (29.5 vs 32.4 kg/m(2); P = .011), and had a higher assigned ASA (American Society of Anesthesiologists) classification (P = .024) in the laparoscopic than in the single-site group. Hypertension was more common in the laparoscopic group (P = .0078). Average docking time was 11.5 (SD 5.7) minutes, and the average console time was 52.8 (SD 22.5) minutes in the single-site group. Total operating time for the laparoscopic and single-site groups was not significantly different (111.5 minutes vs 106.0 minutes; P = .38). There were more conversions to open procedures in the laparoscopic compared to the single-site group (11 vs 1; P = .007). There were no biliary tree injuries and no deaths in either group. CONCLUSION: Single-site robotic cholecystectomy is safe to perform in an inner-city academic hospital setting. Surgical resident involvement does not adversely affect outcomes.

How sick are dialysis patients undergoing cholecystectomy? Analysis of 92,672 patients from the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Although cholecystectomy is one of the most common surgical procedures performed in the United States, there is an absence of data on the risks of cholecystectomy in dialysis patients. Our objective was to analyze the outcomes of cholecystectomy in dialysis patients. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we selected all patients who underwent cholecystectomy from 2005 to 2010. Univariate analysis was performed and logistic and linear regression models were used to obtain risk-adjusted outcomes. The main outcomes were morbidity, mortality, and length of stay. RESULTS: Dialysis was associated with a higher risk of 30-day postoperative morbidity (16.1% vs 3.8%, adjusted odds ratio 1.91, 95% confidence interval 1.18 to 3.10), but not mortality. The average length of stay following any cholecystectomy was 4.1 days longer for dialysis patients (5.5 vs 1.4 days, P < .0001). CONCLUSION: Patients on dialysis who undergo cholecystectomy are at a higher risk for postoperative morbidity, but not mortality.

Predicting the risk of death following coronary artery bypass graft made simple: a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database.

INTRODUCTION: Risk models to predict 30-day mortality following isolated coronary artery bypass graft is an active area of research. Simple risk predictors are particularly important for cardiothoracic surgeons who are coming under increased scrutiny since these physicians typically care for higher risk patients and thus expect worse outcomes. The objective of this study was to develop a 30-day postoperative mortality risk model for patients undergoing CABG using the American College of Surgeons National Surgical Quality Improvement Program database. MATERIAL AND METHODS: Data was extracted and analyzed from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files (2005-2010). Patients that had ischemic heart disease (ICD9 410-414) undergoing one to four vessel CABG (CPT 33533-33536) were selected. To select for acquired heart disease, only patients age 40 and older were included. Multivariate logistic regression analysis was used to create a risk model. The C-statistic and the Hosmer-Lemeshow goodness-of-fit test were used to evaluate the model. Bootstrap-validated C-statistic was calculated. RESULTS: A total of 2254 cases met selection criteria. Forty-nine patients (2.2%) died within 30 days. Six independent risk factors predictive of short-term mortality were identified including age, preoperative sodium, preoperative blood urea nitrogen, previous percutaneous coronary intervention, dyspnea at rest, and history of prior myocardial infarction. The C-statistic for this model was 0.773 while the bootstrap-validated C-statistic was 0.750. The Hosmer-Lemeshow test had a p-value of 0.675, suggesting the model does not overfit the data. CONCLUSIONS: The American College of Surgeons National Surgical Quality Improvement Program risk model has good discrimination for 30-day mortality following coronary artery bypass graft surgery. The model employs six independent variables, making it easy to use in the clinical setting.