Infantile traumatic pericallosal aneurysm: illustrative case.

BACKGROUND: Traumatic aneurysms are a rare sequela of nonaccidental head trauma in infants. The rate of nonaccidental trauma (NAT) in the pediatric population is increasing; therefore, traumatic aneurysms are an important consideration in the evaluation of pediatric patients with abusive head trauma. OBSERVATIONS: A 24-day-old infant with no significant past medical or birth history presented with twitching and poor oral intake for 1 day. The patient was found to have bilateral subdural hematomas, multifocal contusions, and traumatic subarachnoid hemorrhage. NAT work-up was remarkable for a period of repeated and prolonged abuse. Magnetic resonance angiography revealed a right pericallosal traumatic aneurysm that was treated by means of coil and Onyx embolization. LESSONS: Traumatic intracranial aneurysms are a rare but serious sequela of pediatric abusive trauma. Traumatic intracranial aneurysms should be considered in the setting of intracranial pathology associated with high-energy trauma. Despite new methods for the management of traumatic aneurysms, this pathology remains challenging to identify and treat, and the prognosis remains poor because of the diffuse injury often involved in these patients.

Postprocedural necrotizing fasciitis: a 10-year retrospective review.

Necrotizing fasciitis (NF) is a severe soft tissue infection, which has a reported 25 per cent to 60 per cent mortality rate. In addition, NF has been reported to occur after invasive procedures. We present a 10-year retrospective study on postprocedural NF and its differences with community-acquired NF. A retrospective study was conducted from 1996 to 2006. Charts were searched using International Classification of Diseases, 9th Revision codes for NF and gas gangrene. Patients who developed NF in the area of their previous procedure without any other inciting cause of the NF were deemed eligible for the study. Eleven patients met eligibility criteria. Seven patients' initial procedures were elective, whereas four were semiemergent. The median age was 48 years (range, 24-81 years). The time between the initial procedure and operation for NF varied from 3 days to over 3 months. No single laboratory value helped in diagnosing NF. Sixteen different bacteria were isolated from the 11 patients. Ten of 11 patients required multiple debridements. There were four mortalities, three of whom had comorbidities known to predispose to infection. NF is a rare but serious complication after invasive procedures. As a result of important differences that exist between postprocedural and community-acquired NF, we propose that postprocedural NF should be classified in its own subcategory.

Eikenella corrodens causing necrotizing fasciitis after an elective inguinal hernia repair in an adult: a case report and literature review.

We report an unusual case of necrotizing fasciitis in a 43-year-old man after elective inguinal hernia repair. The patient presented to the emergency department 9 days postoperatively with high fevers, tachycardia, and crepitus along his abdominal wall. He was treated with broad-spectrum antibiotics and underwent a diagnostic laparoscopy as well as a wide debridement of all necrotic tissue. Cultures grew out Eikenella corrodens, which, to our knowledge, has only been reported in one other case as a cause of necrotizing fasciitis. Patients can develop necrotizing fasciitis after elective, clean procedures and should be adequately resuscitated, undergo immediate surgical debridement, and receive antibiotics. Laparoscopy can be useful in determining if intraabdominal pathology is the cause of the infection and a wound vacuum-assisted device is a cost-effective way to decrease healing times.

Post-surgical surveillance of locally advanced ileal carcinoids found by routine ileal intubation during screening colonoscopy: a case series.

INTRODUCTION: Carcinoid tumors are the most common type of small bowel tumor, and the incidence is rising. The majority of small bowel carcinoid tumors arise within 60 cm of the ileocecal valve. The addition of ileoscopy to screening colonoscopy can detect asymptomatic small bowel carcinoid tumors and improve long-term prognosis through early surgical resection. Ileoscopy is a brief procedure with a high success rate and minimal complications beyond those of colonoscopy. The use of ileoscopy during screening colonoscopy has led to an increase in the early-stage detection of locoregional small bowel carcinoid tumors that can be completely treated with surgery alone, and as such has improved long-term prognosis in these patients. CASE PRESENTATIONS: Five asymptomatic Caucasian patients, 3 males and 2 females, from 53 to 70 years old (mean age, 60 years old), were diagnosed with locoregional ileal carcinoids during routine colonoscopy with ileoscopy. Since having an ileocolectomy and without adjuvant treatment, no patient has developed tumor recurrence over a follow-up period of one and half to 12 and a half years. CONCLUSION: The early detection of carcinoid tumors by ileoscopy during screening colonoscopy can lead to increased long-term survival in patients with locally invasive disease. The high success rate and brief duration of the procedure, in addition to the lack of associated morbidity and mortality suggest that with further studies, routine ileoscopy during colonoscopy may be promising in the diagnosis of small bowel carcinoid tumors.

Robotic-assisted proctectomy for inflammatory bowel disease: a case-matched comparison of laparoscopic and robotic technique.

BACKGROUND: The objective of this study was to compare short-term outcomes of robotic and laparoscopic proctectomy in patients with inflammatory bowel disease (IBD). METHODS: This is an IRB-approved case-matched review. Seventeen robotic proctectomies (RP), 10 with ileal pouch anal anastomosis (IPAA) and 7 completion (CP), were matched to laparoscopic proctectomies (LP). Short-term and functional outcomes were compared between LP and RP. RESULTS: In CP cohort, operative times were longer in the RP group (351 RP vs 238 LP min, p = 0.03), mean robotic time 90 min. Estimated blood loss (EBL) was similar between RP-CP and LP-CP groups (p = 0.18). Return of bowel function (RBF) was slower in RP-CP group (3.0 vs 1.7 days, p = 0.04), and length of stay (LOS) was longer (6.4 vs 4.1 days, p = 0.02). In the IPAA group, there were no differences between operative times (p = 0.14), robotic time 86 min; EBL (p = 0.15), and postoperative complications. Return of bowel function (3.6 vs 2.6 days, p = 0.3) and LOS (8.5 vs 6.1 days, p = 0.17) were similar between RP and LP. Bowel and sexual function were equivalent between LP and RP-IPAA groups. CONCLUSIONS: Robotic proctectomy is a safe and effective technique for patients with IBD. It is comparable to LP with regard to perioperative outcomes, complications, and short-term functional results.

How important are American Board of Surgery In-Training Examination scores when applying for fellowships?

BACKGROUND: The American Board of Surgery In-Training examination (ABSITE) first was administered in 1975 to evaluate a resident's general knowledge as well as the deficiencies within the resident and surgical program. The added importance of this examination in recent years stems from a correlation between ABSITE performance and performance on the American Board of Surgery qualifying examination. However, data are lacking in regard to how fellowship programs view ABSITE scores when considering applicants. Thus, this study was initiated to determine the importance of the ABSITE for surgical residents applying to fellowships. STUDY DESIGN: Program coordinators and directors of various surgical fellowships were sent a short survey in regard to the ABSITE. The data then were analyzed. RESULTS: One hundred forty-eight surveys were completed, with 74.8% of the programs ranking the importance of ABSITE scores as 3 or 4 (on a scale of 1 through 5). Most programs (78.9%) reported no minimum percentile requirement. Those that did required a mean percentile of 54.4. Of the programs, 57.8% placed a greater emphasis on the senior examination versus the junior examination (p = 0.06). When compared with other application factors, the ABSITE score ranked 3rd behind letters of recommendation and a candidate's residency program. Colon and rectal surgery placed the highest importance on ABSITE scores, whereas transplant surgery placed the lowest importance. CONCLUSION: The ABSITE score is an important factor for residents applying to surgical fellowship; however, more weight is given to candidates' letters of recommendation and his or her residency program. Applicants should aim to score above the 50th percentile to be competitive for most fellowship programs.

Long-term follow-up of patients with fulminant Clostridium difficile colitis.

PURPOSE: The purpose of this study was to determine the long-term survival rate, rate of gastrointestinal continuity restoration, and rate of recurrence following an attack of fulminant Clostridium difficile colitis. MATERIAL AND METHODS: Fulminant C. difficile colitis was defined as any patient who had a bout of C. difficile colitis and required surgical intervention after failing medical therapy. These patients were found through a pathological database search. Follow-up phone calls were made to any patient who survived at least 30 days after being discharged from the hospital following surgical intervention (long-term survivor group). RESULTS: A total of 49 patients were involved in the study. The 30-day mortality rate was 57% (28/49), with an in-hospital mortality rate of 49%. The 5-year survival rate for the long-term survival group was 38% (8/21) and 16.3% for all patients. Gastrointestinal continuity was restored in 20% of the patients. There was one documented recurrence of C. difficile colitis CONCLUSION: Patients who have a bout of fulminant C. difficile colitis have a poor prognosis of surviving longer than 5 years. Restoring gastrointestinal continuity is uncommon and usually reserved for patients with few co-morbidities. Recurrent C. difficile colitis after surgical resection is a rare occurrence.

Relationship of the number of Crohn's strictures and strictureplasties to postoperative recurrence.

BACKGROUND: Strictureplasty is well established as a safe and effective surgical therapy for Crohn's disease (CD). Yet, postoperative recurrence after strictureplasty remains a problem for CD patients, and associated risk factors are still uncertain. The goal of this study was to examine the relationship between recurrence and the number of strictures (NSX) and strictureplasties (NSXP). STUDY DESIGN: The authors' prospectively created database was used to retrospectively identify patients who had undergone strictureplasty between 1984 and 2004. Recurrence was defined as reoperation, and rates were compared based on the NSX and NSXP using Kaplan-Meier curves. Cox regression analyses were used to evaluate the relationship between both NSX and NSXP and recurrence after adjusting for potential confounders. RESULTS: There were 339 strictureplasties performed in 88 patients at initial operation. The 5-year reoperation rates were 14% for patients with 8 strictures (p=0.01). Five-year reoperation rates were 14% for patients with 4 strictureplasties (p < 0.01). In multivariate regression of NSX and NSXP as continuous variables, both were independently associated with recurrence (p