Amani Jambhekar

Readmission Following Laparoscopic Sleeve Gastrectomy.

Background and Objectives: Prior studies have established a 1.7–4.33% readmission rate for laparoscopic sleeve gastrectomy (LSG), a rate that falls within the reported range for other bariatric procedures. The current report describes the incidence of 30-day readmission after primary LSG procedures performed at a single bariatric center of excellence (COE) and examines factors that may be associated with readmission. Methods: Data on 343 consecutive LSG operations performed from February 2010 to May 2014 by a single surgeon (PG) were analyzed. Patients readmitted within 30 d were compared to the remaining patients by using Students t test for continuous variables and the χ2 test for categorical variables. Results: All LSGs were completed laparoscopically with no conversions to open procedures. There were no reoperations, leaks, perioperative hemorrhages, or mortalities. Twelve patients (3.5%) were readmitted; 1 was readmitted twice. There were no identified risk factors for readmission, including patient demographics, comorbidities, and perioperative factors. Notably, 7 (7%) readmissions occurred in the initial 100 patients and 5 (2%) in the remaining 243 patients (P = .04). Clinical pathways were modified after the initial 100 patients; routine contrast esophagograms were no longer performed, and a 1-day routine postoperative stay was adopted. Operative time also decreased from 94.2 ± 23.8 to 78.2 ± 20.0 min (P < .001). Conclusions: Readmission rates after LSG remain in a range similar to those described for other laparoscopic bariatric procedures. Larger prospective studies are needed to identify patterns of complications and readmissions in patients undergoing LSG that may differ from other bariatric procedures.

Delayed presentation of penetrating carotid injury: Two cases and a review of the literature

Background Carotid injuries secondary to a penetrating mechanism of trauma can present immediately, weeks, or even years after the initial injury. Although uncommon, these injuries are associated with significant morbidity and mortality. We present two cases of delayed presentation of carotid injury after penetrating neck trauma, both of which were managed surgically. Case report A 57-year-old male presented with a symptomatic left facial artery pseudoaneurysm two weeks after sustaining a Zone III laceration at angle of mandible. He underwent successful left neck exploration and repair of pseudoaneurysm with complete resolution of his symptoms post-operatively. A 33-year-old female with a history of penetrating right neck trauma repaired primarily 10 years prior in Russia presented with new onset left upper extremity weakness and tingling. Outpatient diagnostic workup revealed a right common carotid aneurysm which was repaired with a polytetrafluoroethylene interposition graft. The patient was discharged without residual neurologic deficits. She represented several years later with neurologic symptoms and an occluded graft. She underwent successful ligation of her graft and was discharged with complete resolution of her symptoms. Conclusion Penetrating carotid injuries can manifest in an immediate or delayed fashion. Computerized tomographic angiography appears to be an appropriate diagnostic tool. Once diagnosed, either endovascular or surgical repair may be valid treatment options.

Blunt traumatic transection of the right common carotid artery

Background Carotid injuries are infrequent following blunt traumatic injury but can have potentially devastating neurologic consequences. We present a case of a 31-year-old male with right common carotid transection after blunt trauma to the neck. Case report A 31-year-old male with no notable medical history presented as a trauma level one activation after riding his bicycle into an open car door causing a Zone II laceration of his right anterior neck. The patient was hemodynamically normal, had an intact airway and had no neurologic deficits on evaluation in the trauma bay. He underwent a computed tomography angiogram of his neck which revealed a focal dissection of the right common carotid artery causing a 70%–80% luminal narrowing suspicious for a grade II injury. The patient was taken to the operating room for exploration of his neck laceration. He was found to have a grade V injury with complete transection of the right common carotid artery through the intima and media with intact adventitia. The arterial injury was repaired with polytetrafluoroethylene interposition graft. Perioperatively, the patient was started on dual antiplatelet therapy. He recovered uneventfully without neurologic deficits. Conclusion Complete transection of the common carotid artery following blunt trauma is rarely reported. Based on a review of the literature regarding blunt carotid injuries, it is reasonable to repair such injuries with prosthetic graft followed by either systemic anticoagulation or dual antiplatelet therapy.

Glomangiosarcoma Arising from a Prior Biopsy Site

Summary: Glomangiosarcoma represents a rare malignant variant of the benign glomus tumor that typically presents as a tender, slowly growing nodule with a predilection for the lower extremities. Unlike their benign counterparts, glomangiosarcomas may display aggressive characteristics such as large size, local invasion, and a tendency to recur after excision. Although wide local excision remains the treatment of choice, rare cases of systemic metastasis have been previously reported. We present a case of glomangiosarcoma arising at a prior biopsy site after excision of an unknown soft tissue lesion.

Multiple Port Site Metastases After Laparoscopic Gastrectomy for Cancer

Introduction: Port site metastases are known phenomena associated with laparoscopic resection of intra-abdominal malignancies, but have not been well documented for gastric cancer. We report a case of port site metastases after laparoscopic subtotal gastrectomy for advanced gastric adenocarcinoma. Case Description: A 71-year-old woman with a history of hypertension and diabetes mellitus presented with melena, weight loss, and signs of gastric outlet obstruction. Preoperative workup demonstrated a T3N1M0 mass extending along the lesser curvature of the stomach with biopsy confirming adenocarcinoma. The patient underwent an uneventful laparoscopic subtotal gastrectomy with D2 lymphadenectomy followed by adjuvant chemotherapy. Thirteen months after surgery, the patient presented with palpable subcutaneous nodules at two of the port sites. computed tomographic (CT) scan confirmed the isolated nodules without distant metastases and fine-needle aspirations confirmed gastric adenocarcinoma. The patient was treated with another cycle of chemotherapy. A post treatment proton emission tomography (PET) scan did not show any other lesions, and the patient was scheduled for resection. During surgery the left upper quadrant mass was found to infiltrate the left colon and an additional mass was found at the prior umbilical port. Pathology was consistent with gastric adenocarcinoma for all the lesions. An excisional biopsy of the right upper quadrant lesion was completed. Conclusion: Given the rarity of port site metastases after gastric adenocarcinoma, there is no conclusive literature regarding the management. Repeat chemotherapy followed by resection, if feasible, appears to be the most reasonable therapeutic intervention if there is no evidence of distant metastases.