Faculty Bibliography

Background/UNASSIGNED:Frequently it is difficult to determine illness severity in hypothermic patients. Our goal was to determine if there are factors associated with illness severity of hypothermic emergency department (ED) patients. Methods/UNASSIGNED:Multi-hospital retrospective cohort. Consecutive patients in 24 EDs (1-1-2012 to 4-30-2015). Hypothermic patients (≤35 °C) were identified using ICD codes. We used hospital admission as marker of illness severity. Student's t-test was used for differences between mean age and temperature for admitted and discharged patients. We calculated the percent of patients admitted by factor, the difference from overall admission rate and 95% confidence interval (CI) of difference. Results/UNASSIGNED:There were 2094 visits with hypothermia ICD code. Of these, 132 patients had initial rectal temperatures ≤35 °C. Females comprised 42%; the mean age was 55 ± 23 years, and overall admission rate was 62%. The percent of patients with alcohol, trauma and found indoors were 39%, 27% and 27%, respectively. For admitted and discharged patients the mean ages were 60 and 48 years, respectively (p = 0.01), and initial mean temperature 32.3 °C vs. 33 °C, respectively (p = 0.07). Found indoors was associated with an 86% admission rate, a 22% increase (95% CI, 3%-34%) compared to overall admission rate. There was no statistically significant difference in admission rates from overall admission rate based on gender, alcohol or trauma. Conclusions/UNASSIGNED:For hypothermic ED patients increased severity of illness was associated with older age and found indoors but not associated with initial temperature, gender, alcohol or trauma. These findings may assist physicians in treatment and disposition decisions.

Many patients with hiatal hernias (HH) are asymptomatic; however, symptoms may include heartburn, regurgitation, dysphagia, nausea, or vague epigastric pain depending on the hernia type and severity. The ideal technique and timing of repair remains controversial. This report describes short-term outcomes and readmissions of patients undergoing HH repair at our institution. All patients who underwent HH repair from January 2012 through April 2017 were reviewed. Patients undergoing concomitant bariatric surgery were excluded. 239 patients were identified and 128 were included. Eighty-eight were female (69%) and 40 were male (31%) with a mean age of 59 years (range 20-91 years) and a mean BMI of 29.2 kg/m² (17-42). Worsening GERD was the most common presenting symptom in 79 (61.7%) patients. Eighty-four laparoscopic cases (65.6%) and 44 robotic assisted (34.4%) procedures were performed. Mesh was used in 59 operations (3 polytetrafluoroethylene; 56 biologic). All hiatal hernia types (I-IV) were collected. Majority were initial operations (89%). Techniques included: Toupet fundoplication in 68 cases (63.0%), Nissen fundoplication in 36 (33.3%), Dor fundoplication in 4 (3.7%), concomitant Collis gastroplasty in 4 (3.1%), and primary suture repair in 20 (15.6%). Outcomes between robotic and laparoscopic procedures were compared. Length of stay was reported as median and interquartile range for laparoscopic and robotic: 1.0 day (1.0-3.0) and 2.0 days (1.0-2.5); p = 0.483. Thirty-day readmission occurred in 9 patients, 7 (8.3%) laparoscopic and 2 (4.6%) robotic; p = 0.718. Two 30-day reoperations occurred, both laparoscopic; p = 0.545. Total of 16 complications occurred; 18.6% had a complication with the use of mesh compared to 8.7% without the use of mesh, p = 0.063. There were no conversion to open modality and no mortalities were reported. Hiatal hernia repair can be performed safely with a low incidence of complications.

BACKGROUND:Traumatic kidney injury is an infrequent event with a wide range of injury patterns. The aim of this paper is to review the incidence, mechanisms of injury, diagnostic methods, and therapeutic indications of renal injury according to the most recent evidence and to perform an analysis of mortality rates on these patients. OBJECTIVES/OBJECTIVE:To perform a systematic review of the literature and a meta-analysis on traumatic kidney injuries. DATA SOURCES/METHODS:A literature search was performed using PubMed, Embase, and Scopus databases. Articles published in English, French and Spanish were selected from 1963 to 2018. MeSH terms utilized were renal trauma, kidney trauma, blunt renal trauma, and penetrating renal trauma. STUDY PARTICIPANTS/METHODS:The eligilibility criteria included only original and human subject articles. Articles not involving human patients, cancer related, review articles, surveys, iatrogenic injuries, pediatric patients, and case reports were excluded from this search. RESULTS:Forty-six articles met the inclusion criteria of which 48,660 patients were identified and included in this review. Gender was reported in 32,918 cases, of which 75.3% of patients were male with a mean age of 33 years. Of the 44,865 patients where the mechanism of injury was described, we identified 36,086 (80.5%) patients that sustained blunt trauma, while 8,779 (19.5%) were due to penetrating mechanisms. Twenty one series with a total of 31,689 patients included the mortality rate. Overall mortality rate with exact binomial 95% confidence interval estimated via random effects model was 6.4% (4.8%-8.4%). CONCLUSIONS:Non-operative management has become the standard in renal trauma management with good results in morbidity and mortality. This has resulted in a decrease in the number of unnecessary iatrogenic nephrectomies and potential improvement in a patient's quality of life. When an invasive treatment is necessary, angioembolization for active bleeding or nephrorrhaphy is usually sufficient.

Reviewed here are multiple mouse models of vertical sleeve gastrectomy (VSG) and Roux-en Y gastric bypass (RYGB) that have emerged over the past decade. These models use diverse approaches to both operative and perioperative procedures. Scrutinizing the benefits and pitfalls of each surgical model and what to expect in terms of post-operative outcomes will enhance our assessment of studies using mouse models, as well as advance our understanding of their translational potential. Two mouse models of bariatric surgery, VSG-lembert and RYGB-small pouch, demonstrate low mortality and most closely recapitulate the human forms of surgery. The use of liquid diets can be minimized, and in mice, RYGB demonstrates more reliable and longer lasting effects on weight loss compared to that of VSG.

Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma.

Background: Gastrocutaneous fistula after gastric bypass is a rare complication. Causes include iatrogenic, traumatic or inflammatory etiologies. Pain and wound complications are debilitating. Multiple approaches exist including percutaneous, endoscopic, and surgical options. Endoscopic approaches involve clipping and fistula plugs and stenting to seal and exclude the fistula.
Method(s): We present a case of a 75-year-old woman with a history of open non-divided gastric bypass 19 years prior that presented with a chronic draining intercostal wound. This started after a thoracoscopic lung and rib resection that was complicated by an infected wound requiring debridement. Surgical history includes splenectomy, abdominoplasty, and ventral herniorrhaphy. The diagnosis was confirmed by fistulogram, which revealed filling of the excluded stomach. Endoscopic approach was not feasible due to the location. Despite multiple abdominal surgeries, a minimally invasive approach was feasible. Access was gained via optical trocar insertion into the right upper quadrant. Additional access ports were placed in the right flank. Extensive adhesive disease was encountered and dissected sharply. The fistula was identified in the left upper quadrant and with great care the tract was dissected circumferentially and sharply divided. The portion of the excluded stomach with the fistula was resected with a linear stapler. The overlying abdominal wall was debrided and packed.
Result(s): The patient had a normal upper GI and was discharged home with local wound care after tolerating a diet on post-operative day 4.
Conclusion(s): A minimally invasive surgical approach is feasible to manage chronic gastrocutaneous fistula in the setting of multiple prior surgeries.
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