Faculty Bibliography

Objectives: Many factors influence the outcomes of complex hernia repair including mesh choice. The objective of the model is to estimate the budget impact of PhasixTM and PhasixTM ST Mesh vs StratticeTM Matrix (biologic) for hospital decision makers in the United States. Methods: This excel based model takes into consideration the product cost, utilization rates, surgery time, hospital length of stay (LOS), rates of seroma, wound dehiscence, postoperative infection, reoperation and readmission. It is flexible to allow for per patient, per year or cumulative savings over 3 and 5 years. The material costs and cost of outcomes are reported separate and combined to address different audiences. The model incorporates various data sources (published literature, specific hospital data, Premier database analytics, etc.), related to the use of Phasix Mesh and StratticeTM Matrix in hernia repair. Budget impact is calculated by comparing costs in scenarios with or without PhasixTM Mesh and PhasixTM ST Mesh. Results: In a hypothetical scenario of 125 patients, introduction of PhasixTM and PhasixTM ST would result in a total budget savings of $617,943 in the first year if 60% of the StratticeTM Matrix cases are converted to PhasixTM/ST Mesh. $195,336 of the savings comes from the difference in material cost vs $422,607 from the difference in outcomes. Cumulative savings over 3 and 5 years would be $2,265,793 and $3,913,642 respectively (assuming PhasixTM Mesh and PhasixTM ST Mesh replaced 80% of StratticeTM Matrix usage in years 2-5). Conclusions: In this budget impact analysis, the uptake of PhasixTM Mesh and PhasixTM ST Mesh resulted in considerable budget savings compared to the use of StratticeTM Matrix. This may be attributed to reductions in LOS, rates of reoperation and readmission, unit cost and complications, which may lead to savings for the hospital and improved patient outcomes in the long term

Abstract Background: The purpose of this analysis was to provide a concise report of the literature on the burden of intestinal failure associated with short bowel syndrome (SBS-IF) in adults, focused on clinical and humanistic issues important to clinicians and payers. Scope: A literature search was performed using the National Library of Medicine PubMed database ( http://www.ncbi.nlm.nih.gov/pubmed ) with the search term 'short bowel syndrome' limited to adult populations and English-language reports published from January 1, 1965, to January 18, 2013. Citations were assessed for relevance and excluded articles focused on single case studies, colon fermentation, absorption of medications with PN/IV, surgical technique, mesenteric artery complications/surgery, and transplantation focus. Additional hand searches were performed using the terms 'short bowel syndrome' AND 'cost', and 'home parenteral nutrition' AND 'cost', along with the exclusion criteria described above. Findings: Despite advances in management in recent decades, SBS-IF continues to carry a high burden of morbidity and mortality. In the absence of sufficient intestinal adaptation following resection, many patients remain dependent on long-term parenteral nutrition and/or intravenous fluids (PN/IV). Although potentially life saving, PN/IV is costly, invasive, and associated with numerous complications and deleterious effects on health and quality of life. Surgical interventions, especially intestinal transplantation, are costly and are associated with substantial morbidity and high mortality. New therapies, which show promise in promoting intestinal rehabilitation and reducing dependence on PN/IV therapy, are the subject of active research. Conclusions: Overall, the available literature suggests that although SBS-IF affects a relatively small population, the clinical and humanistic burden is significant, and there is an unmet need for effective therapeutic options that target the underlying problem of inadequate absorptive capacity of the remaining intestine. Consequently, many patients with SBS-IF remain dependent on long-term PN/IV support, adding to the burden imposed by the underlying disorder.

A Meckel's diverticulum may result in a number of complications including hemorrhage, obstruction, and inflammation. We report a case of a gangrenous Meckel's diverticulum secondary to axial torsion, which has been reported only four times in adults and once in children in the past 28 years

OBJECTIVE: The recognition that splenectomy renders patients susceptible to lifelong risks of septic complications has led to routine attempts at splenic conservation after trauma. In 1990, the authors reported that over an 11-year study period involving 193 patients, splenorrhaphy was the most common splenic salvage method (66% overall) noted, with nonoperative management employed in only 13% of blunt splenic injuries. This report describes changing patterns of therapy in 190 consecutive patients with splenic injuries seen during a subsequent 6-year period (1990 to 1996). An algorithmic approach for patient management and pitfalls to be avoided to ensure safe nonoperative management are detailed. METHODS: Nonoperative management criteria included hemodynamic stability and computed tomographic examination without shattered spleen or other injuries requiring celiotomy. RESULTS: Of 190 consecutive patients, 102 (54%) were managed nonoperatively: 96 (65%) of 147 patients with blunt splenic injuries, which included 15 patients with intrinsic splenic pathology, and 6 hemodynamically stable patients with isolated stab wounds (24% of all splenic stab wounds). Fifty-six patients underwent splenectomy (29%) and 32 splenorrhaphy (17%). The mean transfusion requirement was 6 units for splenectomy survivors and 0.8 units for nonoperative therapy (85% received no transfusions). Fifteen of the 16 major infectious complications that occurred followed splenectomy. Two patients failed nonoperative therapy (2%) and underwent splenectomy, and one patient required splenectomy after partial splenic resection. There no missed enteric injuries in patients managed nonoperatively. The overall mortality rate was 5.2%, with no deaths following nonoperative management. CONCLUSIONS: Nonoperative management of blunt splenic injuries has replaced splenorrhaphy as the most common method of splenic conservation. The criteria have been extended to include patients previously excluded from this form of therapy. As a result, 65% of all blunt splenic injuries and select stab wounds can be managed with minimal transfusions, morbidity, or mortality, with a success rate of 98%. Splenectomy, when necessary, continues to be associated with excessive transfusion and an inordinately high postoperative sepsis rate

OBJECTIVE: While immunosuppression 2 degrees to human immunodeficiency virus (HIV) infection should logically render HIV+ trauma victims more prone to infection after injury, little data is available regarding trauma outcome in this group of patients. Since the helper CD4+ lymphocyte count is a marker for progression of HIV-associated diseases, we examined the relationship between CD4+ counts, Injury Severity Score (ISS), and bacterial infectious complications in HIV+ trauma patients. METHOD: Retrospective review of 56 consecutive HIV+ trauma patients treated at a Level I trauma center. RESULTS: Nine patients (15%) developed significant infectious complications (four pneumonias, three soft-tissue infections, one urinary tract infection, one wound infection) with no pattern to the causative agents. Evaluation of CD4+ counts, white blood cell counts, serum albumin levels, blood transfusion requirements, and ISS revealed that only the ISS was associated with infectious complications. CONCLUSION: Despite the profound immunosuppression in this group of patients, the incidence of bacterial infectious complications was independent of the CD4+ count (p = 0.958), but was associated with increases in the ISS (p = 0.003)

This review of 14 recent publications encompassing 495 patients highlights the current role of the nonoperative management of adult blunt hepatic injuries. When careful inclusion criteria were met, the most important of which is hemodynamic stability, a 94% success rate was achieved, clearly attesting to the safety and efficacy of this approach. A 0% liver-related mortality in these 495 patients was achieved, and there were no documented missed enteric injuries. Delayed hemorrhage that led to laparotomy occurred in 2.8% of patients. The mean length of hospital stay was 13 days, and the mean transfusion requirement was 1.9 units of blood per patient. Computed axial tomography scanning was essential and played an integral role in delineating the extent of the injury, identifying other intra-abdominal injuries that would mandate immediate laparotomy, and following the progress of injury resolution. Overall, 34% of blunt liver injuries were managed nonoperatively. As of 1993, however, available data confirms that 51% of adult reported blunt hepatic injuries have been treated nonoperatively. Rigid adherence to the described guidelines may allow the majority of blunt hepatic injuries to be treated nonoperatively. It should be stressed, however, that this method of patient management should only be undertaken at institutions where the appropriate resources necessary to deal with this patient population are readily available

Epithelioid hemangioendothelioma is an uncommon intermediate-grade vascular tumor which most often presents in soft-tissue and is known to occasionally metastasize. A primary cardiac occurrence of this tumor was resected from the left atrium of a 71 year-old woman. Four months later, she underwent gluteal exploration and resection of three nodules from her right buttock. These nodules, which resembled the previously resected tumor but showed features of malignant transformation, were identified as metastatic epithelioid hemangioendotheliomas. To the best of our knowledge, only one case of primary cardiac epithelioid hemangioendothelioma has been previously reported in the literature. We believe ours is the second such case and the first to demonstrate distant metastases. This rare case of primary cardiac epithelioid hemangioendothelioma with distant metastases is illustrative of many of the known features and behaviors of the tumor. The case is reviewed and discussed alongside a review of recent topical literature

Nonparasitic secondary cysts (pseudocysts) of the spleen are uncommon and usually result from blunt abdominal trauma. A 3-year experience with 7 consecutive cases of posttraumatic splenic pseudocysts suggests an increased prevalence of this clinical entity. This report describes 7 adult patients (5 men and 2 women) with a mean age of 32 years, all of whom sustained relatively minor trauma within 5 years of admission. Persistent epigastric or left upper quadrant pain led to a CT scan diagnosis of splenic cysts that varied in size from 7 cm to 15 cm. Each patient underwent resection of the cyst-bearing portion of the spleen with preservation of the remaining normal splenic parenchyma. There were no deaths or complications in the entire group. Because posttraumatic splenic cysts are rare, the accumulation of a significant data base leading to firm conclusions is lacking.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical lesions of the falciform ligament are rare. Clinically, they present most often as a cystic abdominal mass, and less often as an abscess. Two cases of falciform ligament lesions are reported. The literature, histology, anatomy, clinical manifestations, and surgical management are detailed. Computerized axial tomography (CAT scan) is an essential tool in arriving at a correct preoperative diagnosis. Complete excision of the lesion is curative