Significance of the Hepatic Falciform Artery.

The authors present a case that highlights the anatomy of the hepatic falciform artery and describes its importance. The hepatic falciform artery is an anatomic variant that arises from the hepatic vasculature and provides arterial communication between the abdominal wall and the liver. It is essential to identify its presence, especially when surgery or embolization is planned for that area.

A Case of Iatrogenic Splenic Injury Following Routine Colonoscopy With Possible Influence of Unique Anatomy Due to Severe Scoliosis.

Iatrogenic splenic injury is a rare complication of all abdominal surgeries. Despite the procedure's overall safety, colonoscopy is now the procedure most frequently associated with iatrogenic splenic injury. A 58-year-old male with a past medical history of hypertension, lung cancer in remission, colon polyps, and severe scoliosis presented for grade three splenic laceration two days following a routine colonoscopy. He had no recent history of injury or other inciting events that could have led to traumatic injury. Non-operative management included splenic artery embolization and transfusion of one unit of packed red blood cells, after which he improved in the hospital and was discharged home in stable condition. This case postulates the possible influence of his severe scoliosis, and thus altered abdominal viscera anatomy, on his iatrogenic splenic injury, as well as the potential importance of investigating scoliosis as a risk factor for difficult colonoscopy or even iatrogenic splenic injury during colonoscopy.

Gastric Ischemia Secondary to Abdominal Distension.

Gastric ischemia has been reported in the literature mainly as case reports and case series. It is uncommon because of its excellent blood supply. Patients with atherosclerosis and vascular insufficiency are at risk for gastric ischemia, especially with gastric distension. Workup may reveal radiographic findings that denote ischemia and would prompt surgical intervention. However, these patients with vascular insufficiency tend to be poor surgical candidates, which can present a dilemma. The authors report two cases where non-operative management for gastric ischemia was successfully accomplished.

Bariatric Surgery Improves Renal Function: a Large Inner-City Population Outcome Study.

BACKGROUND: Bariatric surgery is associated with improved renal dysfunction in general population studies. The study examined the effects of bariatric surgery on renal function in a predominantly Hispanic and African American population at a community hospital in New York, USA. METHODS: This retrospective study analyzed prospectively collected bariatric surgical data from 2247 patients (89% female) who underwent bariatric surgery at a single center. Changes in glomerular filtration rate (eGFR), urine albumin-creatinine ratio (UACR), micro- and macroalbuminuria, and hyperfiltration, which were measured preoperatively and then yearly for 3 years postoperatively, were evaluated with t tests and logistic regression analysis, after adjusting for confounding variables. The mean age of the patients at surgery was 37.1 years; the mean preoperative body mass index was 45 ± 7 kg/m2. RESULTS: The results obtained 3 years postoperatively showed the following significant improvements compared with the preoperative values: mean UACR decreased from 40.3 to 11.1 mg/g, mean eGFR improved from 79.4 to 87.3 mL/min, the prevalence of microalbuminuria decreased from 13.7 to 6.2%, the prevalence of macroalbuminuria decreased from 2.5 to 0%, and the prevalence of hyperfiltration decreased from 4.4 to 2.7% (all P < .0001). In adjusted multivariate regression analysis, these results remained significant after adjusting for age, sex, race, type of surgery, and presence of diabetes mellitus or hypertension. CONCLUSION: In this large study at an inner-city hospital, bariatric surgery was associated with significant improvements in renal dysfunction parameters. These results could assist with informed decisions regarding indications for bariatric surgery.

Weight Loss Outcomes following Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in an Ethnically Diverse Bariatric Population: Which Is More Effective?

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) have comparable weight loss outcomes in a general bariatric population. OBJECTIVES: This study aimed to investigate whether similar outcomes can be observed in Hispanic and African American population. Settings. Community Hospital in New York, New York, United States. METHODS: The 5-year prospective data of patients who underwent LRYGB and LSG at a single center were retrospectively reviewed. The long-term weight loss outcomes between patients who had LRYGB and LSG were compared after adjusting for age, sex, race, diabetes mellitus, and hypertension with the linear mixed-effects or logistic regression model. RESULTS: Most patients were Hispanic (59.2%) and African American (22.7%). The mean% total weight loss (%TWL) values of patients with BMI <45 kg/m2 who underwent LRYGB and LSG were 73% and 62% after 1 year, 69% and 56% after 2 years, and 71% and 54% after 5 years, respectively. In patients with a BMI of 45-50 kg/m2 who underwent LRYGB and LSG, the mean %TWL values were 69% and 56% after 1 year, 75% and 58% after 2 years, and 57% and 45% after 5 years, respectively. Meanwhile, the %TWL values of patients with BMI >50 kg/m2 who had LRYGB and LSG were 53% and 42% after 1 year, 53% and 45% after 2 years, and 49% and 36% after 5 years, respectively. All results were statistically significant (p < 0.0001) and remained valid after adjusting for cofactors. CONCLUSION: Thus, LRYGB had consistent and sustained long-term weight loss outcomes compared with LSG in a predominantly ethnically diverse patient population with different BMI. Our study had several limitations in that it is retrospective in nature and some patients were lost to follow-up during the study period.

Resuscitative Thoracotomy for Multiple Gunshot Wounds With Cardiac Tamponade Despite Pericardial Window.

This report reviews the indications and complications of resuscitative thoracotomy in the trauma patient as seen with the clinical course of a 19-year-old male who experienced postoperative pericardial tamponade after a bilateral resuscitative thoracotomy with pericardiotomy. This patient presented to the hospital in critical condition with 31 gunshot wounds (GSWs) distributed over the chest, abdomen, and extremities. After undergoing an initially successful resuscitative thoracotomy, the patient continued to bleed into his chest at a greater rate than the chest tubes were able to adequately evacuate. Despite the presence of a large pericardial window, clotted blood led to cardiac tamponade. Subsequent bedside reopening of thoracotomy under conscious sedation (ketamine, fentanyl, and midazolam) was required to evacuate the clots and stabilize the patient. This case provides the opportunity to discuss several interesting points for managing the traumatized patient, including indications for resuscitative thoracotomy, use of conscious sedation for bedside major surgery, and complications of clamshell thoracotomy, and ethics of resource allocation.

Ruptured Hepatic Artery Aneurysm.

Aneurysmal ruptures are a life-threatening pathology, and while the aorta is the principal location, any aneurysmal rupture can be fatal. Most result from chronic diseases, such as hypertension, diabetes, and vasculitis. Nevertheless, a rupture can result in acute decompensation and must be recognized and addressed quickly to limit morbidity and mortality. The authors describe a case of a 66-year-old female who presented to the emergency department (ED) for abdominal pain and syncope. Even though imaging did not explicitly show the specific site of rupture of the hepatic artery, the positive Rapid Ultrasound for Shock and Hypotension (RUSH) exam and aortic dissection on computed tomography angiography along with her clinical picture (hypotension, abdominal pain, decreased capillary refill, grey skin) raised our suspicions for critical pathology. Exploratory laparotomy revealed a ruptured hepatic artery aneurysm. Her hospital course was complicated by ischemic necrosis of the gallbladder, spleen, and liver, requiring cholecystectomy, splenectomy, and partial hepatectomy, but she was discharged to rehabilitation and expected to make a recovery. This case displays the importance of using ultrasonography early to aid in expedited diagnosis and treatment as well as maintaining a high suspicion for vascular pathology in the setting of hemorrhagic shock.

Improvement in glycated hemoglobin A1C after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in an ethnically diverse population with diabetes.

BACKGROUND: Obesity is a well-known risk factor for the development of type 2 diabetes. The efficacy of bariatric surgery in reducing weight with resulting improvement in type 2 diabetes has been reliably demonstrated. OBJECTIVES: We investigated and compared the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) on glycated hemoglobin (HbA1C) levels in a predominantly Hispanic and black population. SETTINGS: Community Hospital in New York, New York, United States. METHODS: This is a retrospective review of a 5-year data from a single center where patients with diabetes who underwent LRYGB or LSG were included. HbA1C levels and body mass index were analyzed preoperatively and then annually postoperatively for up to 5 years. Improvements in HbA1C were compared between the 2 groups after adjusting for age, sex, race, and hypertension with linear mixed-effects or logistic regression models. RESULTS: Of the 676 included patients, 84.8% were females and the mean age was 47 years. HbA1C levels decreased significantly (P < .05) in the entire group at 1 (21%), 2 (20%), 3 (20%), 4 (18%), and 5 (14%) years. Compared with LSG, LRYGB patients displayed greater improvement in HbA1C levels at 1 year (25% versus 17%, P = .001). The differences in the reduction of HbA1C between LRYGB and LSG for the other time intervals were not significant (P > .05), 24% versus 17% (2 yr), 22% versus 16% (3 yr), 22% versus 13% (4 yr), and 17% versus 10% (5 yr). Changes in body mass index were not correlated to changes in HbA1C at various study points. CONCLUSION: Both LRYGB and LSG resulted in significant decreases in HbA1C levels and are correlated with changes in body mass index. LRYGB had the greatest effect at 1 year postoperatively. There was no significant difference in HbA1C reduction for LRYGB and LSG after 1 year postoperatively in this predominantly Hispanic and black cohort.

Phlegmonous Gastritis in a Bariatric Patient After Sleeve Gastrectomy.

Phlegmonous gastritis is a rare and progressive fatal condition that affects the mucosa and submucosa of the gastric wall. It can be localized or diffuse, affecting the entire stomach. It usually presents with upper gastrointestinal symptoms, such as nausea, vomiting, and hematemesis, along with systemic symptoms, including fever, chills, and fatigue. Risk factors include mucosal injury, surgery, hypoacidity, and immunosuppression that can be seen in human immunodeficiency virus (HIV)-positive or alcoholic patients. We present a case of phlegmonous gastritis which developed after a laparoscopic sleeve gastrectomy. The patient presented with epigastric pain, nausea, and chills two months post-sleeve gastrectomy. The diagnosis was made with computed tomography (CT) scan of the abdomen. She was managed successfully with CT-guided drainage and antibiotics.

Incidental Left Ventricular Aneurysm Discovered after Chest Pain Following a Motor Vehicle Collision.

We report the case of a female with a history of coronary artery disease who came in with chest pain after a motor vehicle collision. Imaging revealed an incidental left ventricular aneurysm. The presentation and management of left ventricular aneurysms are discussed, along with imaging findings on computed tomography, plain radiography, and ultrasonography.

Hypopituitarism After Traumatic Brain Injury.

Acquired hypopituitarism is associated with traumatic brain injury. This neuroendocrine dysfunction can cause both short-term and long-term morbidity resulting in a cognitive, physiological, and behavioral decline, which increases the burden of the disease and the cost of care. Data in the trauma literature is derisory on this subject. The aim of this review is to edify clinicians on this condition, outline the screening criteria and methods for hypopituitarism after traumatic brain injury, and bring awareness to the chronic effects.

Optimizing Care for Trauma Patients with Obesity.

Obesity is a growing epidemic that has been contributing to the increasing cost of healthcare. Its prevalence is now approximately 37%. Morbid obesity is associated with increased morbidity and mortality in trauma patients. An increased recognition of obesity as a chronic disease and a better understanding of its pathophysiology can allow for proper preparation and accommodative measures to improve resuscitation and subsequent care, thereby improving trauma outcomes. The aim of this review is to provide an overview of the scope of the problem. This review also provides evidence-based recommendations for the optimal resuscitation sequence for obese patients.

Resuscitative Endovascular Balloon Occlusion of the Aorta as an Adjunct in a Patient with Neurogenic Shock.

Aortic occlusion is used during trauma resuscitation for patients with profound shock and cardiac arrest. Aortic occlusion increases coronary and cerebral perfusion permitting time for interventions in an attempt to salvage moribund patients. Resuscitative endovascular occlusion of the aorta (REBOA) is a less invasive method of aortic occlusion and its indications are being defined, but it is used primarily for noncompressible torso hemorrhage. This case is the first report of the use of REBOA for neurogenic shock in a trauma patient. The patient presented after a motorcycle accident with altered mental status and hypotension. The patient was resuscitated with blood products and REBOA used as an adjunct to maintain cardiac and cerebral perfusion. The patient underwent stabilization of his spinal injuries and is currently undergoing rehabilitation. There were no complications related to the REBOA.

Clostridium sordelli causing malignant edema in a trauma patient: a case report and review of literature.

Clostridium sordelli infection is a rare but potentially lethal infection associated with abortions, injury, contaminated wounds, and illicit drug use. It causes a recognizable syndrome with marked leukocytosis. Rapid diagnosis and aggressive sepsis management is required for optimal outcome. We report a case in a trauma patient with delayed presentation after sustaining facial trauma with soil contamination. The critical care management is summarized and a review of the literature.

A case of recurrent pneumatosis intestinalis.

Pneumatosis intestinalis (PI), defined as free gas in the bowel wall, is associated with autoimmune conditions, drugs, pulmonary disease and many other etiologies. Patients with findings of PI may have variable clinical presentations, ranging from asymptomatic to acute abdomen necessitating urgent surgery. Here, we present the case of an individual with recurrent PI whose suspected etiologies ultimately varied from benign to lethal between visits. We discuss the clinical management of each case, perform post-hoc application of a proposed treatment algorithm, and highlight areas for future research.

A case series of closed head trauma with pituitary stalk disruption resulting in hypopituitarism.

INTRODUCTION: Traumatic brain injury (TBI) is one of the main causes of morbidity and mortality in young trauma patients with resultant multi-organ effects. Hypopituitarism following TBI can be debilitating and life threatening. TBI which causes hypopituitarism may be characterized by a single head injury, such as from a motor vehicle accident, or by chronic repetitive head trauma, as seen in combative supports including boxing, kick-boxing, and football. In the majority of cases, a diagnosis of hypopituitarism can be entirely missed resulting in severe neuro-endocrine dysfunction. We present a case series of two patients diagnosed with hypopituitarism after TBI and treated appropriately with favorable outcome. CASE PRESENTATIONS: The first case is a 34 year-old male, who presented to the emergency department with blunt head trauma after a motor vehicle accident while riding his bicycle. He suffered from severe cranio-facial injuries, resulting in multifocal hemorrhagic contusions, epidural hematoma, and extensive cranio-facial fractures involving the sinuses. The patient developed persistent hypotension with a blood pressure as low as 60/40 mmHg on hospital day three. The second case is a 56 year-old male with a history of schizophrenia, who suffered traumatic brain injury after he was hit by a train. The patient sustained multiple facial fractures, pneumocephalus and C2/7 transverse processes fractures. He also had persistent hypotension, unresponsive to standard treatment. Investigation revealed a deficiency of anterior pituitary hormones resulting from pituitary axis disruption. DISCUSSION: Hypopituitarism is becoming an increasingly recognized complication following TBI, ranging from total to isolated deficiencies. Traumatic Brain Injury is a major public health problem and is one of the leading causes of disability. Understanding and recognizing pituitary dysfunction after TBI can lead to better outcomes and improved quality of life. CONCLUSION: Patients with major head injury and, in particular, those with fractures of the base of the skull, must be closely monitored for signs and symptoms of endocrine dysfunction. Appropriate dynamic pituitary-function screening should be performed.

Blunt Laryngeal Fracture Status Post Fall on a Paintball Gun.

Laryngeal fracture is a rare but potentially lethal injury. A high degree of suspicion along with an expeditious investigation is warranted to prevent airway complications. The initial assessment of the airway is vital as the patient can suffer a severe anoxic brain injury. If the patient is stable, a computed tomography (CT) scan of the neck should be obtained; this was done urgently for our patient and was managed without any extraneous intervention. We report a case of a 38-year-old man that presented to the emergency room with anterior neck pain after falling onto the back of a paintball gun. The patient was managed conservatively and favorable outcomes were obtained.

Retrograde jejunojejunal intussusception in a pregnant female after laparoscopic Roux-en-Y gastric bypass.

Adult intussusception is a rare complication after laparoscopic Roux-En-Y gastric bypass (LRYGB) surgery. Incidence of intussusception is on the rise as the demand of bariatric surgeries is increased to treat morbid obesity. Among the bariatric surgeries, LRYGB gastric bypass results in significantly higher weight loss with thinning of the mesentery resulting in increased risk for intussusception. Majority of intussusception cases after gastric bypass have been reported in non-pregnant patients. We report a case of retrograde jejunojejunal intussusception in 6 weeks pregnant female following laparoscopic gastric bypass, which was diagnosed with abdominal magnetic resonance imaging and managed successfully with resection and revision of the anastomosis.

Paraplegia Following Spinal Cord Contusion from an Indirect Gunshot Injury.

Spinal cord injuries are debilitating and life threatening. Paraplegia due to direct traumatic gunshot injury to the spinal cord is common. The most common cause of spinal cord injury is road traffic accidents. This is followed by spinal cord injury due to a fall from a height. Most of the spinal cord injuries due to gunshot wounds occur as a result of direct traumatic effects. We present a rare case of a 49-year-old male with trauma. He developed paraplegia after a gunshot wound injury to the neck and contusion to the spinal cord, with no direct trauma. Paraplegia due to direct gunshot injury can have many different outcomes. In our case, the patient was managed conservatively, and the outcome was favorable.

Successful laparoscopic repair of gastro-gastric fistula following Roux-en-Y gastric bypass at Harlem Community Hospital.

Gastro-gastric fistula is a communication between the gastric remnant and gastric pouch. It is a rare complication of Roux-en-Y gastric bypass. It is caused by anastomotic leak, marginal ulcers, distal obstruction or erosion from foreign body. In this case report, we are presenting a successful laparoscopic repair of gastro-gastric fistula in a patient who presented with weight gain after initial loss.