Faculty Bibliography

An aortocaval fistula, a rare abnormal vascular communication between the aorta and inferior vena cava, is most commonly associated with abdominal aortic aneurysms (AAAs). Other factors leading to aortocaval fistula formation include atherosclerosis, collagen vascular diseases, vasculitis, hematogenous infections, prior spinal surgery, malignancy and radiation exposure. In rare instances, aortocaval fistulas may be discovered incidentally on abdominal imaging. We report an unusual case of an incidental aortocaval fistula in a 93-year-old male patient with an unruptured AAA, presenting with shortness of breath, malaise and lethargy. The patient had no other obvious risk factors for aortocaval fistula formation. Multidetector computed tomography angiography helped identify the fistula, and the patient was eventually transferred to hospice for comfort measures. This case highlights the importance of detailed imaging and preoperative planning in managing aortocaval fistulas and associated AAAs.

Solitary fibrous tumors (SFTs) are rare mesenchymal pleural neoplasms with an overall good prognosis and low recurrence rate if completely resected and if degree of differentiation is favorable. Within the last decade, advances in research have led to more reliable methods of differentiating SFTs from other soft tissue tumors. Historically, several markers were used to distinguish SFTs from similar tumors, but these markers had poor specificity. Recent evidence showed NAB2-STAT6 fusion gene to be a distinct feature of SFTs with 100% specificity and sensitivity. Surgical resection, with an emphasis on obtaining negative margins, is the mainstay of treatment for SFTs. Preoperative planning with detailed imaging is imperative to delineate the extent of disease and vascular supply. One important radiologic distinction to aid delineation of a pleural-based tumor compared to a pulmonary parenchymal-based tumor is the angle that the tumor forms with the chest wall, which is obtuse for a pleural-based tumor, and acute for tumors of the lung parenchyma. Often, preoperative tissue diagnosis is not available, and surgery is both diagnostic and curative. Intraoperatively, emphasis should be on complete resection with negative margins. SFTs are resected via several approaches: thoracotomy, sternotomy with the option of hemi-clamshell extension, video-assisted thoracoscopic surgery, and robotic approach, which is increasingly being used and is our preference. We recommend a minimally invasive approach for most lesions, and have resected SFTs of the pleura that are up to 12 cm with the robotic approach. However, the current literature often cites 5 cm as the cut off for an open thoracotomy. Nevertheless, even with larger tumors, a minimally invasive robotic approach is our preference and practice. For giant SFTs (> 20 cm), an open approach may be preferable. Multiple thoracotomies and rib resection may be required to gain adequate exposure and ensure complete resection in these tumors. However, it is noteworthy that most of these tumors have a soft consistency and thus, once bagged, can easily be removed minimally invasively, and thus minimally invasive approach should not be completely ruled out. Recurrence in SFTs usually results from incomplete resection and redo surgery may portend a favorable prognosis.

Gastric bypass has grown in popularity in recent years due to its high efficacy in achieving long-term weight loss in patients with morbid obesity. Gastric bypass has been described to further exacerbate baseline nutritional deficiencies due to reduced gastric capacity and malabsorption. In rare cases, when protein deficiency is severe, Kwashiorkor disease may arise. The incidence of Kwashiorkor specifically following gastric bypass is rare, with an incidence of 4.7%. We report a case of a female patient who underwent a gastric bypass and subsequently developed Kwashiorkor. Physicians' suspicion of index for Kwashiorkor should be high for patients presenting with signs or symptoms of severe malnutrition following weight-loss procedures.
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BACKGROUND:This study observes the trends and patterns among trainees during the coronavirus disease 2019 (COVID-19) pandemic and their response to resident education and hospital/program support. METHODS:An anonymous online 31-question survey was distributed to medical students and postgraduate year residents. Topics included were demographics, clinical responsibilities, educational/curricula changes, and trainee wellness. Descriptive analysis was performed for each set of demographic groupings as well as 2 and 3 group comparisons. RESULTS:< .0001). CONCLUSION/CONCLUSIONS:We aim to provide continued educational support for our trainees' clinical development and well-being during the COVID-19 pandemic.

PURPOSE/OBJECTIVE:Bariatric surgery is emerging as an effective treatment for obesity and the metabolic syndrome. Recently, we demonstrated that Roux-en-Y gastric bypass (RYGB), but not vertical sleeve gastrectomy (VSG), resulted in improvements to white adipose physiology and enhanced brown adipose functioning. Since beneficial alterations to liver health are also expected after bariatric surgery, comparing the post-operative effects of RYGB and VSG on liver physiology is essential to their application in the treatment of non-alcoholic fatty liver disease (NAFLD). MATERIALS AND METHODS/METHODS:The effects of RYGB and VSG on liver physiology were compared using diet induced mouse model of obesity. High-fat diet (HFD) was administered for 12 weeks after surgery and alterations to liver physiology were assessed. RESULTS:Both RYGB and VSG showed decreased liver weight as well as reductions to hepatic cholesterol and triglyceride levels. There were demonstrable improvements to NAFLD activity score (NAS) and fibrosis stage scoring after both surgeries. In RYGB, these beneficial changes to liver function resulted from the downregulation of pro-fibrotic and upregulation anti-fibrotic genes, as well as increased fatty acid oxidation and bile acid flux. For VSG, though similar alterations were observed, they were less potent. However, VSG did significantly downregulate pro-fibrotic genes and showed increased glycogen content paralleled by decreased glycogenolysis which may have contributed to the resolution of NAFLD. CONCLUSION/CONCLUSIONS:RYGB and VSG improve liver physiology and function, but RYGB is more efficacious. Resolutions of NAFLD in RYGB and VSG are achieved through different processes, independent of weight loss.

INTRODUCTION/BACKGROUND:Stop the Bleed (STB) is a national training program aiming to decrease the mortality associated with life-threatening bleeding due to injury. The purpose of this study was to evaluate the efficacy and confidence level of security personnel placing a tourniquet (TQ) compared to civilians. METHODS:Pre and post questionnaires were shared with security personnel (Group 1) and civilians (Group 2). Both groups were assessed to determine comfort level with TQ placement. Time and success rate for placement was recorded pre- and post-STB training. A generalized linear mixed model or generalized estimating equations was used to compare pre and post measurements. RESULTS:There were 234 subjects enrolled. There was a statistically significant improvement between the pre- and post-training responses in both groups with respect to comfort level in placing a TQ. Participants also demonstrated increased familiarity with the anatomy and bleeding control after STB training. A higher successful TQ placement was obtained in both groups after STB training (Pre-training: Group 1 [17.4%], Group 2 [12.8%]; Post-training: Group 1 [94.8%], Group 2 [92.3%]). Both groups demonstrated improved time to TA placement with a longer mean time improvement achieved in Group 1. Although the time to TQ placement pre-and post-training was statistically significant, we found that the post-training times between Groups 1 and 2 were similar (P = .983). CONCLUSIONS:Participants improved their confidence level with the use of hemorrhage control techniques and dramatically increased the rate and time to successful placement of a TQ. While civilians had the greatest increase in comfort level, the security personnel group saw the most significant reduction in the time to successful TQ placement. These findings highlight the critical role of STB in educating and empowering both civilians and security personnel in bleeding control techniques.

BACKGROUND:We hypothesized that the outcomes of trauma patients with a body mass index (BMI) equal to or greater than 30 compared to patients with BMI less than 30 would not differ at a level 1 trauma center that is also a Metabolic and Bariatric Surgery Center of Excellence in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP). STUDY DESIGN/METHODS:Patients equal to and greater than 18 years old treated between 1/1/2018 and 12/31/2020 were included. Demographics, BMI, comorbidities, and outcomes (hospital-LOS, ICU-LOS, blood products used, and mortality) were compared between 2 groups: obese (BMI ≥30) vs non-obese (BMI <30). RESULTS:< .0001). When adjusted for age, sex, DM, dementia, ISS, and ICU admission, there was no statistically significant difference in hospital-LOS (4.30 [95% CI: 4.10, 4.52] vs 4.48 [95% CI: 4.18, 4.79]) or mortality. No statistical differences were seen between the 2 groups in blood product use. CONCLUSIONS:Obesity did not correlate with poorer outcomes at an ACS-verified level 1 Trauma Center and Bariatric Surgery Center of Excellence. Further studies are needed to determine whether outcomes vary at hospitals without both designations.

Background and Objectives/UNASSIGNED:Revisional bariatric surgery continues to increase. Laparoscopic adjustable gastric banding (LAGB) after previous Roux-en-Y gastric bypass (RYGB), known colloquially as "band-overpouch" has become an option despite a dearth of critically analyzed long-term data. Methods/UNASSIGNED:Our prospectively maintained database was retrospectively reviewed for patients who underwent band-overpouch at our Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Center of Excellence in a 18-year period ending October 31, 2021. We evaluated: demographics, comorbidities, operative procedures, and outcomes (30-day and > 30-day). Results/UNASSIGNED:During the study period, of 4,614 bariatric procedures performed, 42 were band-overpouch with 39 (93%) being women. Overall, mean age was 49.8 years (range 26-75), a mean weight 251 pounds (range 141-447), and mean body mass index 42.4 (range 26-62). Comorbidities included: hypertension (n = 31; 74%), diabetes (n = 27; 64%), obstructive sleep apnea (n = 26; 62%), gastroesophageal reflux disease (n = 26; 62%), and osteoarthritis (n = 25; 60%). All procedures were performed laparoscopically with no conversions to open. Mean length of stay was 1.2 days (range 1-3). Mean follow-up time was 4.2 years (range 0.5-11). Mean excess weight loss was 14.9%, 24.3%, and 28.2% at 6 months, 1 year and ≥ 3 years, respectively. There was one 30-day trocar-site hematoma requiring transfusion. Long-term events included: 1-year (1 endoscopy for retained food; 1 internal hernia), 3-year (1 LAGB erosion; 1 LAGB explant), 4-year (1 anastomotic ulcer), 6-year (1 LAGB explant and Roux-en-Y revision), and 8-year (1 LAGB erosion). One 5-year mortality occurred (2.4%), in association with hospitalization for chronic illness and malnutrition. Band erosions were successfully treated surgically without replacement. Conclusion/UNASSIGNED:Band-overpouch is associated with moderate excess weight loss and has good short-term safety outcomes.

Background and Objectives/UNASSIGNED:Despite the growth of minimally invasive surgery (MIS) in many specialties, open colon surgery is still routinely performed. The purpose of this study was to compare outcomes and costs between open colon and minimally invasive colon resections. Methods/UNASSIGNED:test was used for categorical variables. Multiple Logistic and Quintile regression were used for multivariable analyses. Results/UNASSIGNED:A total of 88,405 elective colon resections (open: 56,599; minimally invasive: 31,806) were reviewed. A significantly larger proportion of patients undergoing minimally invasive surgery were obese (body mass index > 30) compared to those undergoing open surgery (71.4% vs. 59.6%; p < 0.0001). As compared to minimally invasive colectomy, open colectomy patients had: a longer median length of stay [median (range): 7 (4-13) days vs. 4 (3 - 6) days, p < 0.0001], higher 30-day readmission rate [n = 8557 (15.1%) vs. 2815 (8.9%), p < 0.0001], higher mortality [n = 2590 (4.4%) vs. 107 (0.34%), p < 0.0001], and a higher total direct cost [median (range): $13,582 (9041-23,094) vs. $9013 (6748 - 12,649), p < 0.0001]. Multivariable models confirmed these findings. Conclusion/UNASSIGNED:Minimally invasive colon surgery has clear benefits in terms of length of stay, readmission rate, mortality and cost, and the routine use of open colon resection should be revaluated.

BACKGROUND AND AIMS/OBJECTIVE:Peroral endoscopic myotomy (POEM) is becoming the treatment of choice for achalasia. Data beyond 3 years are emerging but limited. We herein report our 10-year experience, focusing on long-term efficacy and safety including the prevalence, management, and sequelae of postoperative reflux. METHODS:This was a single-center prospective cohort study. RESULTS:Six hundred ten consecutive patients received POEM from October 2009 to October 2019 for type I achalasia in 160 (26.2%), II in 307 (50.3%), III in 93 (15.6%), untyped achalasia in 25 (4.1%), and nonachalasia disorders in 23 (3.8%). Two hundred ninety-two (47.9%) patients had prior treatment(s). There was no aborted POEM. Median operation time was 54 minutes. Accidental mucosotomies occurred in 64 (10.5%) and clinically significant adverse events (csAEs) in 21 (3.4%) patients. There were no adverse events (AEs) leading to death, surgery, interventional radiology interventions/drains, or altered functional status. At a median follow-up of 30 months, 29 failures occurred, defined as postoperative Eckardt score >3 or need for additional treatment. The Kaplan-Meier clinical success estimates at year 1, 2, 3, 4, 5, 6, and 7 were 98%, 96%, 96%, 94%, 92%, 91%, and 91%, respectively. These are highly accurate estimates because only 13 (2%) patients were missing follow-up assessments. One hundred twenty-five (20.5%) patients had reflux symptoms more than once per week. At a median of 4 months, the pH study was completed in 406 (66.6%) patients and was positive in 232 (57.1%) and endoscopy in 438 (71.8%) patients and showed reflux esophagitis in 218 (49.8%), mostly mild. CONCLUSION/CONCLUSIONS:POEM is exceptionally safe and highly effective on long-term follow-up, with >90% clinical success at ≥5 years.