Uncommon Presentation of Clostridioides difficile in the Small Bowel: A Case Report and Review of Literature.

Clostridioides difficile infection (CDI) is a prevalent source of hospital-acquired diarrhea. The most common presentation of CDI is colitis. In cases of fulminant colitis/toxic megacolon, a colectomy and end ileostomy are part of the treatment plan. There is evidence to suggest that it may be beneficial to surgically treat severe complex CDI by constructing a loop ileostomy for fecal stream diversion followed by colonic lavage, also referred to as the Pittsburgh protocol, which has demonstrated decreased death rates in this patient population. In our case study, we present a rare case of a 60-year-old female patient diagnosed with fulminant small bowel CDI requiring resection of the necrotic small bowel. This was followed by creating an ileostomy and the Pittsburgh protocol, leading to a complete recovery. With an increasing incidence of CDI, it is important to be aware of the small bowel C. difficile infection and its treatment.

Functional outcomes of hybrid hiatal hernia repair.

Gastroesophageal reflux disease (GERD) results in a total healthcare cost of 12.3 billion dollars to the United States annually. GERD is often seen with hiatal hernias. Our study aims to compare short-term functional outcomes and postoperative symptom relief afforded by hiatal hernia repair with transoral incisionless fundoplication (TIF), together known as hybrid repair, to those of hiatal hernia repair with surgical fundoplication (conventional repair). We performed a retrospective chart review on 112 consecutive patients who underwent robot assisted laparoscopic hiatal hernia repair at a community hospital by a single surgeon. We found that the short-term functional results and symptom relief with hybrid repair were no superior to those with conventional repair. We did not find a significant difference between hybrid and conventional repair in terms of in 30 day complications, ER visits or inpatients admissions. The number of patients who were symptomatic at delayed follow-up was not significantly different between both the groups. As such, short-term functional outcomes and symptom relief with hybrid hiatal hernia repair are no superior to those with conventional repair. Therefore, surgical repair of hiatal hernia with surgical fundoplication remains the standard of care until further data is available on long-term outcomes of the hybrid approach.

Hybrid hiatal hernia repair: is it cost-effective?

Fundoplication is often added to the crural repair for long-term relief of reflux in patients undergoing hiatal hernia repair. Fundoplication can be achieved surgically or with endoscopic means such as trans-oral incisionless fundoplication (TIF). Patients with hiatal hernias larger than 2 cm may undergo surgical hiatal hernia repair with concomitant TIF (hybrid repair). Our study aims to analyze the resources utilized for hybrid repair and compare it with hiatal hernia repair with surgical fundoplication (conventional repair). We conducted a retrospective review of 112 consecutive patients who underwent robotic-assisted hiatal hernia repair. Patients who underwent some form of fundoplication were selected and then divided into two groups-surgical fundoplication (conventional approach) or hybrid approach. This is a pool of patients operated by a single surgeon at a community hospital. Multiple variables were analyzed. The mean operative time was 39 min less; also the mean length of stay was 10 h less in hybrid approach group as compared to conventional repair group. Although statistically significant, there was no meaningful clinical significance to these findings. Cost analysis was performed for direct costs as well as indirect costs. Neither the 30-day outcomes nor the cost-effectiveness for hybrid repair was superior to those of conventional repair. Therefore, in our experience at the community-level hospital, we conclude that hiatal hernia repair with surgical fundoplication is more cost-effective than surgical repair of hiatal hernia with TIF.

Cryptorchidism as an obscure cause of adhesive small bowel obstruction in an adult, a case report.

INTRODUCTION AND IMPORTANCE: Cryptorchidism is seen in 3% of fullterm neonates. Rarely, it may cause small bowel obstruction. Knowledge of this presentation of cryptorchidism is essential to treat bowel obstruction arising due to cryptorchidism before the patient suffers complications. CASE PRESENTATION: We present a case of a patient who underwent exploratory laparotomy for small bowel obstruction that did not resolve with conservative management. At laparotomy, on initial exploration, this patient had adhesive bands causing the small bowel obstruction. On further exploration, the bands were found to arise from a cryptorchid testis. CLINICAL DISCUSSION: Cryptorchidism is a common finding among newborns and needs to be corrected by 1 year of age. Failure to correct cryptorchidism in a timely manner can result in complications such as bowel obstruction. CONCLUSION: Thorough intraoperative exploration is key at operation for all cases of small bowel obstruction, so as to find and treat anatomic causes of obstruction. Congenital causes of bowel obstruction should be suspected in all unexplained cases of bowel obstruction and may be revealed by careful physical examination and thorough intraoperative exploration.

Success of endoscopic vacuum therapy for persistent anastomotic leak after esophagectomy - A case report.

INTRODUCTION: Endoscopic vacuum (endovac) therapy has shown excellent outcomes when used for esophageal anastomotic leaks. The results of endovac therapy are superior to those of other endoscopic therapies for esophageal leaks. CASE PRESENTATION: We present a case of a 70-year-old male with esophageal adenocarcinoma who underwent Ivor Lewis esophagogastrectomy that was complicated by an esophageal leak. After failure of multiple endoscopic therapies (i.e. stents and clips), he responded well to endovac therapy. DISCUSSION: Endovac therapy is extremely useful for the treatment of esophageal leaks. The widespread use of endovac therapy is feasible, even in smaller community hospitals. CONCLUSION: Endovac therapy is a valuable tool that can be used widely for the management of esophageal leaks. Commercially available devices need to be developed in order to facilitate endovac placement and exchange so that the procedure is less dependent on the skill of the operator.

Gastrosplenocolic fistula secondary to non-Hodgkin B-cell lymphoma.

Gastrocolic fistula (GSF) is a rare entity that arises mainly from splenic or gastric lymphoma. Gastric and splenic lymphomas can also fistulate with other organs, including the pleura and the colon, but there has been no reported case to best of our knowledge of a fistula involving three different organs. We hereby present the case of a female patient with gastrosplenocolic fistula secondary to non-Hodgkin B-cell lymphoma. We performed an en bloc partial gastrectomy with splenectomy and partial left colon resection with colostomy. GSF can be treated with chemotherapy. However, when the definite diagnosis is unclear or GSF is causing serious complications such as bleeding or active infection, we believe surgical excision is the treatment of choice.

Aortic root surgery with circulatory arrest: Predictors of prolonged postoperative hospital stay.

OBJECTIVE: Little is known about the outcomes of aortic root operations that involve inducing hypothermic circulatory arrest for relatively extensive proximal aortic surgery. We attempted to identify predictors of postoperative hospital length of stay (LOS) and factors that affect postoperative recovery. METHODS: During 2006-2014, 247 of 265 patients (93.2%) with disease extending into the aortic arch survived aortic root operations (206 elective, 41 urgent/emergent) in which hypothermic circulatory arrest with moderate hypothermia was used. Stepwise multivariate regression analysis was performed to identify predictors of LOS (as a continuous variable) and prolonged LOS (defined as LOS >9 days, the median for the cohort). By this definition, 111 patients (45%) had prolonged LOS and 136 (55%) did not. RESULTS: Preoperative factors that independently predicted longer LOS in the entire cohort included age (P = .0014), redo sternotomy (P = .0047), and intraoperative packed red blood cell (PRBC) transfusion (P = .0007). Redo sternotomy and intraoperative PRBC transfusion also predicted longer LOS in 3 subgroup analyses: one of elective cases, one from which total arch replacement procedures were excluded, and one limited to patients who were discharged home. Age predicted longer LOS in the non-total arch (hemiarch) replacement patients. Ventilator support >48 hours (P < .0001) was associated with longer LOS. Elective aortic valve-sparing root replacement predicted a shorter LOS than valve replacement in multivariate regression analysis (P = .028). CONCLUSIONS: In patients undergoing aortic root surgery with hypothermic circulatory arrest for disease extending into the aortic arch, reducing intraoperative PRBC transfusion except when absolutely necessary may reduce postoperative LOS and expedite recovery. Performing aortic valve-sparing root replacement, when feasible, may also reduce LOS.

Moderate hypothermia at warmer temperatures is safe in elective proximal and total arch surgery: Results in 665 patients.

OBJECTIVE: To evaluate adverse outcomes after elective aortic arch surgery performed at higher or lower temperatures (24.0°C-28.0°C vs 20.1°C-23.9°C) within the wide range of moderate hypothermia. METHODS: Over a 9-year period, a total of 665 patients underwent elective proximal (n = 479) or total (n = 186) arch replacement with moderate hypothermia and antegrade cerebral perfusion. Circulatory arrest was initiated at an actual temperature of 20.1°C to 23.9°C in the lower-temperature group (n = 334; 223 proximal, 111 total) and at 24.0°C to 28.0°C in the higher-temperature group (n = 331; 256 proximal, 75 total). Composite adverse outcome was defined as operative mortality or persistent neurologic event or persistent hemodialysis at discharge. Multivariate logistic regression analysis was used to model adverse outcome. In addition to the actual temperature, a new, balanced variable, "predicted temperature," was analyzed to eliminate surgeon bias. We used this variable in a propensity score-matching analysis to validate the multivariate analysis results. RESULTS: A composite adverse outcome occurred in 7.2% of cases. Operative mortality was 5.1%. The rate of postoperative persistent neurologic deficits was 2.4%. No significant differences were found between the lower- and higher-predicted temperature groups within the moderate hypothermia range in the propensity score-matching analysis. The higher-actual temperature group had a lower rate of ventilator support at >48 hours (P = .036) and less need for tracheostomy (P = .023). Packed red blood cell transfusion and previous coronary artery bypass independently predicted composite adverse outcome (P = .0053 and .0002, respectively), operative mortality (P = .0051 and .0041), and postoperative stroke (P = .045 and .048). Cardiopulmonary bypass time independently predicted composite outcome (P = .0005), operative mortality (P < .0001), ventilatory support for >48 hours (P < .0001), and renal dysfunction (P = .0005). CONCLUSIONS: In elective proximal or total arch surgery, higher temperatures (≥24.0°C-28.0°C) within the wide range of moderate hypothermia (20.1°C-28°C) are safe and, compared with colder temperatures, not associated with significantly different rates of composite and adverse outcomes.

The impact of temperature in aortic arch surgery patients receiving antegrade cerebral perfusion for >30 minutes: How relevant is it really?

OBJECTIVE: We examined the early outcomes and the long-term survival associated with different degrees of hypothermia in patients who received antegrade cerebral perfusion (ACP) for >30 minutes. METHODS: During a 10-year period, 544 consecutive patients underwent proximal and total aortic arch surgery and received ACP for >30 minutes and 1 of 3 levels of hypothermia: deep (14.1°C-20°C; n = 116 [21.3%]), low-moderate (20.1°C-23.9°C; n = 262 [48.2%]), and high-moderate (24°C-28°C; n = 166 [30.5%]). A variable called "predicted temperature" was used in propensity-score analysis. Multivariate analysis was done to evaluate the effect of actual temperature on outcomes. RESULTS: The operative mortality rate was 12.5% (n = 68) overall and was 15.5%, 11.8%, and 11.5% in the deep, low-moderate, and high-moderate hypothermia patients, respectively (P = .54). The persistent stroke rate was 6.6% overall and 12.2%, 4.6%, and 6.0% in these 3 groups, respectively (P = .024 on univariate analysis). On multivariate analysis, actual temperature was not associated with mortality, but lower temperatures predicted persistent stroke and reoperation for bleeding. In the propensity-matched subgroups, the patients with predicted deep hypothermia had (nonsignificantly) greater rates of persistent stroke (12.2% vs 4.9%; relative risk, 1.08; 95% CI, 0.87-1.15) and reoperation for bleeding (14.6% vs 2.4%; relative risk, 1.14; 95% CI, 0.87-1.15) than the patients with predicted moderate hypothermia. On long-term follow-up (mean duration, 5.12 years), 4- and 8-year survival rates were 62.3% and 55.7% in the deep hypothermia group and 75.4% and 74.2% in the moderate hypothermia group (P = .0015). CONCLUSIONS: In proximal and arch operations involving ACP for >30 minutes, greater actual temperatures were associated with less stroke and reoperation for bleeding. There were no significant differences among the predicted hypothermia levels, although a trend toward a higher rate of adverse events was noticed in the deep hypothermia group. Long-term survival was better in the moderate hypothermia group.

Moderate hypothermia ≥24 and ≤28°C with hypothermic circulatory arrest for proximal aortic operations in patients with previous cardiac surgery.

OBJECTIVES: To determine whether, in patients with previous cardiac operations, moderate hypothermia (between 24 and 28°C) for hypothermic circulatory arrest (HCA) during antegrade cerebral perfusion (ACP) is safe for use during surgery on the proximal aorta and transverse aortic arch. METHODS: Over a 7-year period, 118 patients underwent ascending aortic and hemiarch repair (n = 70; 59.3%), total arch replacement (n = 47; 39.8%) or ascending aortic replacement to treat porcelain aorta (n = 1; 0.9%). Simultaneous procedures included aortic root repair or replacement (n = 33; 28.0%) and coronary artery bypass grafting (n = 21; 17.8%). All patients had previously undergone cardiac operations via a median sternotomy. Eighteen patients (15.3%) had more than 1 previous sternotomy, and 24 patients (20.3%) required emergent/urgent operation. Median cardiopulmonary bypass, cardiac ischaemic, circulatory arrest and ACP times (min) were 136.0 [118-180 interquartile range (IQR)], 91.0 (68-119 IQR), 34.0 (21-59 IQR) and 33.5 (20-59 IQR), respectively. The median temperature when HCA was initiated was 24.2°C (24.1-24.8°C IQR). RESULTS: The operative mortality rate was 10.2% (n = 12). Six patients (5.1%) had a permanent stroke, and 16 patients (13.6%) had a composite adverse outcome (operative mortality and/or a permanent neurological event and/or permanent haemodialysis at discharge). Preoperative renal disease was significantly more prevalent (P= 0.020) and the median circulatory arrest time significantly longer (48.5 vs 33 min; P= 0.058) in patients with composite adverse outcomes. Multivariable analysis of the redo patients showed that age (P =0.025), preoperative renal disease (P =0.024) and ACP time (P =0.012) were independent risk factors for a new postoperative renal injury. CONCLUSIONS: Moderate hypothermia for HCA during ACP is being used with increasing frequency, but has not been thoroughly evaluated in patients undergoing cardiovascular reoperations. Our experience suggests that in patients with previous cardiac surgery who are undergoing hemiarch and total aortic arch operations, moderate hypothermia is safe and produces respectable results.