Faculty Bibliography

Introduction: Portomesenteric vein thrombosis (PMVT) is a rare but serious postoperative complication following bariatric surgery, with an incidence rate ranging from 0.3 to 1%. Due to the nonspecific symptoms, a high index of suspicion is needed to make the diagnosis. If left untreated, PMVT can progress to intestinal ischemia, perforation and peritonitis. Case Presentation: A 51-year-old female presented to the Emergency Department five days after laparoscopic sleeve gastrectomy (LSG) complaining of worsening abdominal pain and low grade fevers. A CT scan and upper GI series were performed with no evidence of leak or abscess, and the patient was admitted for observation. On hospital day two, the patient had worsening abdominal pain, and an episode of emesis. An ultrasound revealed a new moderate amount of intraperitoneal free fluid. A CT scan was repeated which revealed a thrombus in the splenic and superior mesenteric veins. Upon further discussion, the patient admitted to a previous diagnosis of antithrombin III deficiency and non compliance with anticoagulation. The patient was subsequently started on therapeutic anticoagulation with resolution of her abdominal pain. The remainder of the hospitalization was uncomplicated and she was discharged home on oral anticoagulation.
Discussion(s): It has been well established that morbid obesity is a significant prothrombotic factor for patients undergoing bariatric procedures. There has been increasing interest in identifying other factors which may contribute to hypercoagulability during these procedures. Possible etiologies for PMVT following LSG include thrombophilia, venous stasis from increased intra-abdominal pressure or patient positioning, and intraoperative manipulation of vasculature. Increasing interest has turned toward identifying patients who may be predisposed to PMVT following LSG. In a recent multicenter review of 40 patients who developed PMVT after LSG, 92% had a hematologic abnormality. The most common abnormality identified was elevation of Factor VIII (76%). Other significant abnormalities included deficiencies in antithrombin III, factor V leiden, and protein C/S.
Conclusion(s): Patients undergoing LSG have an increased risk of developing PMVT. A high index of suspicion is important for prompt diagnosis and expeditious treatment. Up to 90% of PMVT after LSG can be successfully treated with therapeutic anticoagulation alone

Introduction: The focused assessment with sonography in trauma (FAST) exam provides a rapid bedside screening tool for intraperitoneal free fluid and solid organ injuries. Blood clots within an injured organ may have similar echogenicity to that of the parenchyma. The sensitivity for detection of solid organ injury is therefore more limited and ranges from 41-44%. Case Presentation: A 52-year-old male presented as a Level 2 Trauma notification after plywood fell onto him from fifteen feet. Upon presentation he was evaluated according to ATLS protocol. Secondary survey was significant for suprapubic tenderness and abrasions to bilateral hips. A FAST exam was performed, showing echogenic fluid filling the bladder. A foley catheter was placed and gross hematuria was noted. Xray in the trauma bay showed fractures of the left superior and inferior pubic rami. Subsequently a CT cystogram was performed which showed large clot within the bladder with small extraperitoneal extravasation. The injury was managed with transurethral foley and gentle irrigation.
Discussion(s): The bladder is well protected by the bony pelvis, making rupture relatively uncommon in blunt trauma. However, it remains an important injury to rule out because mortality rates can be be as high as 22%. Pelvic fracture with associated gross hematuria is an indication for immediate cystography. Blunt extraperitoneal bladder rupture should be treated conservatively, with nonoperative management having comparable outcomes to primary repair. Relative contraindications to conservative management of extraperitoneal bladder rupture include bone fragments protruding into the bladder, open pelvic fractures, and concomitant rectal injuries. The use of transurethral catheters are preferred over suprapubic catheters, resulting in fewer complications and fewer days of catheterization.
Conclusion(s): FAST exam is less sensitive for diagnosing solid organ injury and ranges from 41-44%. Hematuria and pelvic fractures are seen together in 90% of bladder ruptures. When both are present in blunt trauma, cystography should be performed. Extraperitoneal bladder injuries should be managed non operatively with drainage transurethral catheter alone. Intraperitoneal bladder injuries should be managed by primary repair with transurethral catheter or suprapubic tube drainage

Background: Inguinal hernia repair is one of the most common general surgery procedures with over 600,000 performed annually in the United States. When compared to traditional open inguinal hernia repair (OIHR), laparoscopic inguinal hernia repair (LIHR) has been associated with faster postoperative recovery rates and lower postoperative pain. With advances in the robotic platform, robotic inguinal hernia repair (RIHR) is an available technique that is currently being explored. This study examines LIHR and RIHR as described in literature to see if one is superior to the other. Study Design: Search terms: "Inguinal Hernia Repair" "Robotic Inguinal Hernia Repair," "Laparoscopic Inguinal Hernia Repair." A systematic search was performed in August 2017 of Medline, PubMed, and relevant journals using the above-listed search terms. Out of 80 articles found, only 8 were suitable for this content review. Results: Operative time in RIHR averaged 99 minutes as compared to 68 minutes in LIHR. Patients undergoing RIHR had an average complication rate of 5% with a recurrence rate of 0.06%. For obese patients, a lower percentage experienced postoperative complications when undergoing RIHR as compared to OIHR (unadjusted: 2.7% vs. 11.5%, p=0.005; and matched: 3.2 % vs. 10.8%, p=0.047), with bilateral robotic repairs more easily conducted in obese patients (unadjusted 29.7% vs. 16.8%, p=0.019; and unadjusted 35.1% vs. 11.5%, p\0.0001-respectively). More complicated procedures were performed using R-TAPP (n=11 vs. n=1, p=0.0001) with nearly identical (69.12 +/-35.13 min, R-TAPP; 69.05+/-26.31, L-TEP) intraoperative and postoperative complication rates. Similarly, average pain scores in recovery (2.5 vs 3.8, p=0.02) were significantly less after R-TAPP. However, mean operative time (77.5 vs 60.7 min, p=0.001) and room time (109.3 vs 93.0 min, p=0.001) were longer but with less recovery time and reported pain. Surgical complications including hematomas (3.9%), seromas (2.6%), and trocar site infection (1.3%) resolved with antibiotics, with a 2.6% postoperative complication rate. Conclusion: RIHR repair is a safe alternative to LIHR, with fewer postoperative complications and a faster recovery time. However, operative time as well as OR room time is significantly longer, which may increase overall cost. Further high quality randomized controlled trials are needed to assess efficacy and outcomes of RIHR

Background: Morbid obesity, a common medical concern with significant health risks, has a prevalence of 10.4% among U.S. adults. Bariatric surgery provides effective weight loss for morbidly obese patients with improvement in their comorbid conditions. Traditionally, routine intraoperative drain placement (IDP) and postoperative esophagram (UGIS) were thought to identify early postoperative complications. Recently, these interventions have been scrutinized for their effectiveness. We hypothesized that IDP and postoperative UGIS do not alter outcomes in bariatric surgery and only increase hospital length of stay (LOS). Methods: Two cohorts, each consisting of 100 patients from either 2015 or 2017 were analyzed from our institution. In the 2015 cohort, all patients had IDP and an UGIS on postoperative day 1, prior to starting a clear liquid diet. In the 2017 cohort, no patients had IDP or UGIS, but instead were started on a clear liquid diet on postoperative day 1, in the absence of vomiting. All patients in each cohort underwent either a laparoscopic sleeve gastrectomy or a Roux-en-Y gastric bypass. A retrospective study was performed to analyze whether there was a significant difference in post-operative complications, length of stay, and operating room time between these two cohorts. Results: The average bariatric procedure duration was 85.04 minutes in 2015 as compared to 124.68 minutes in 2017, with a p-value of\0.001. This discrepancy can be attributed to the greater number of surgeons operating in 2017, 8 in 2017 compared to 3 in 2015. The length of stay in 2015 averaged 2.42 days, compared to 1.44 days in 2017, with a p-value of\0.001. For patients with complications, all were Clavien-Dindo Grade 1-2 and did not require any invasive interventions. The complication rate was 0.07 in 2015 and 0.02 in 2017 with a p-value of 0.089 with all complications being early minor ones. The readmission rate within 30 days was the same in both groups, 0.03. Conclusion: Our retrospective study results support the initial hypothesis that IDP and postoperative UGIS do not alter outcomes in bariatric surgery. Moreover, we found that stopping routine use of IDP and UGIS significantly reduced LOS while complication rates remained low. Therefore, we do not recommend routine use of IDP and UGIS in the uncomplicated bariatric patient

Both animal and cell culture data support a beneficial role of interferon gamma in the amelioration/treatment of pulmonary fibrosis. Despite this, two large randomized clinical trials failed to show a clinical response to subcutaneous interferon gamma. This negative response was associated with low/non-detectable levels of interferon gamma levels in the BAL fluid. Data from normal volunteers supports the inability of interferon gamma delivered subcutaneously to reach the lung epithelial lining fluid or activate BAL cells. We completed a phase I clinical trial with inhaled interferon gamma for 80 weeks in 10 patients with IPF. Prior studies in IPF patients suggest that aerosol interferon gamma is not detectable in BAL fluid if obtained > 24 hours after nebulization. Patients tolerated treatment well with stabilization in FVC and DLCO over 80 weeks. BAL was obtained at baseline and between 1 and 4 hours after treatment with inhaled interferon gamma. BAL fluid showed significant increases in interferon-gamma levels (17.07 +/- 13.67 pg/ml to 1077 +/- 501.97 pg/ml p=0.062) This level was associated with immunomodulation of lung environment. Inhaled interferon gamma may be beneficial in the treatment of IPF