Gainosuke Sugiyama

Traumatic Ventricular Septal Defect

Traumatic ventricular septal defect (VSD) is an uncommon occurrence in cases of penetrating cardiac injury with an incidence of only 1% to 5%. The mainstay of diagnosis of VSDs is the transthoracic echocardiogram. We report a case of an occult traumatic VSD, which was not seen on echocardiography, but was later found on a high-resolution computed tomographic scan of the chest.Traumatic ventricular septal defect (VSD) is an uncommon occurrence in cases of penetrating cardiac injury with an incidence of only 1% to 5%. The mainstay of diagnosis of VSDs is the transthoracic echocardiogram. We report a case of an occult traumatic VSD, which was not seen on echocardiography, but was later found on a high-resolution computed tomographic scan of the chest.

Single-Site Robotic Cholecystectomy at an Inner-City Academic Center.

Introduction: We investigate the safety and efficacy of single-site robotic cholecystectomy compared to laparoscopic cholecystectomy at an inner-city academic medical center. Materials and Methods: Retrospective analysis comparing single-site robotic to laparoscopic cholecystectomies from August 1, 2013, to January 31, 2015, was conducted. Age, gender, race, body mass index (BMI), total operative time (docking and console time for robotic cases), length of stay, comorbidities, and conversion to open procedures were examined. The χ2 and Students t test were used for categorical and continuous data, respectively. A P ≤ 0.05 was considered statistically significant. Results: From August 2013 to January 2015, 70 single-site robotic cholecystectomies and 70 laparoscopic cholecystectomies were performed. Patients were older (mean age, 40.3 years vs 47.6 years; P = .0084), had a higher mean BMI (29.5 vs 32.4 kg/m2; P = .011), and had a higher assigned ASA (American Society of Anesthesiologists) classification (P = .024) in the laparoscopic than in the single-site group. Hypertension was more common in the laparoscopic group (P = .0078). Average docking time was 11.5 (SD 5.7) minutes, and the average console time was 52.8 (SD 22.5) minutes in the single-site group. Total operating time for the laparoscopic and single-site groups was not significantly different (111.5 minutes vs 106.0 minutes; P = .38). There were more conversions to open procedures in the laparoscopic compared to the single-site group (11 vs 1; P = .007). There were no biliary tree injuries and no deaths in either group. Conclusion: Single-site robotic cholecystectomy is safe to perform in an inner-city academic hospital setting. Surgical resident involvement does not adversely affect outcomes.

Robot-Assisted Transabdominal Preperitoneal Ventral Hernia Repair.

Background and Objectives: We believe that complications due to the mesh used in ventral hernia repairs can be reduced by using the natural barrier afforded by the peritoneum. This can be challenging to do laparoscopically, however we felt that the robot-assisted laparoscopic approach reduces the difficulty in placing the mesh in the preperitoneal space, and we want to share our early experiences with this approach. We describe the surgical technique used in robot-assisted laparoscopic transabdominal preperitoneal (TAPP) ventral hernia repair with mesh. In addition, we evaluate its feasibility and present preliminary perioperative results. Methods: We performed robot-assisted laparoscopic TAPP ventral hernia repairs in 3 patients in the spring of 2015. Demographic information and defect size were measured. Conversion from a laparoscopic to an open procedure was the primary outcome variable. Results: There were 3 cases of robot-assisted TAPP ventral hernia repair with mesh. The mean age of the patients was 49 years, the mean body mass index was 32.6 kg/m2, and the mean operative time was 163.7 minutes. The mean defect size was 1219.0 mm2. There were no conversions to open during this early learning phase. All patients were discharged home within the 24-hour postoperative period. No complications were noted during a mean follow-up of 3 months. Conclusions: We present our early experience with robot-assisted TAPP ventral hernia repair. We note that because of improved ergonomics and wristed instrumentation, the robotic platform enabled creation of peritoneal flaps and complete coverage of mesh with peritoneum after primary closure of the defect. The robotic approach is feasible and may provide a better environment for mesh integration and protection. Further investigations with long-term follow-up are needed to verify that this technique is effective in reducing mesh-related intra-abdominal complications.

A case of isolated splenic tuberculosis

Highlights • We discuss a case of isolated splenic tuberculosis.• Extra-pulmonary tuberculosis can present in the immunocompetent patient.• Splenectomy is indicated when GI bleeding due to portal hypertension and splenomegaly occurs, as well as failure of medical therapy, cytopenia and multiple splenic abscess.

Management of ampullary carcinoid tumors with pancreaticoduodenectomy.

A 66 year old female was found to have an ampullary mass on endoscopic examination. A pancreaticoduodenectomy was performed and the pathology was consistent with carcinoid tumor. Carcinoid tumors of the ampulla of Vater are rare tumors of the gastrointestinal tract, accounting for 0.3-1% of gastrointestinal carcinoids. Management of ampullary carcinoid tumor with pancreaticoduodenectomy is in accordance with current recommendations.

Is it time to rethink our management of dialysis patients undergoing elective ventral hernia repair? Analysis of the ACS NSQIP database

PurposeThe number of patients on chronic dialysis is steadily increasing each year. There is little data that describes the outcomes in dialysis patients following elective ventral hernia repair, one of the most common general surgery procedures. Our objective was to compare the mortality and morbidity rates in dialysis versus nondialysis patients following elective ventral hernia repair.MethodsWe analysed the ACS NSQIP database to identify patients that underwent elective ventral hernia repair from 2005 to 2010. Univariate analysis and multivariate logistic regression was performed on all patients included. The main outcome variables were mortality and morbidity, length of hospital stay, and return to the operating room.ResultsFollowing elective ventral hernia repair, dialysis patients were more likely to die within 30 days or experience at least one morbidity. Dialysis patients were more likely to experience an infectious, pulmonary or vascular complication. Patients on dialysis also had a 2-fold greater risk of returning to the operating room within 30 days and stayed in the hospital an average of 1.3 days longer than nondialysis patients. Similar results were found after adjustment for demographics and comorbidities using multivariable logistic regression.ConclusionThis is one of the largest studies demonstrating the outcomes of a specific general surgery procedure in dialysis patients. Chronic dialysis prior to elective ventral hernia repair is associated with an increased risk of 30-day mortality, morbidity, and return to the operating room. Dialysis patients are susceptible to infectious, pulmonary, and vascular post-operative complications.

Prophylactic hypothermia and neuromuscular blockade to limit myocardial oxygen demand in a critically anemic Jehovah's Witness after emergency surgery

Management of anemic patients refusing blood transfusion remains challenging. Concomitant coronary artery disease further complicates management. We sought to decrease the likelihood of cardiac events by employing hypothermia and neuromuscular blockade, in addition to limited phlebotomy, in a critically anemic Jehovahs Witness patient following emergent colectomy. The patients hemoglobin concentrations were trended with serial blood gases. Neuromuscular blockade was instituted with cisatracurium, followed by hypothermia to a target of 32°C. The patients lowest hemoglobin levels occurred on postoperative day 3 before beginning to rise. There were no postoperative cardiac events reported during the patients course of stay. She recovered well with no evidence of anemia or cardiac events at 1-year follow-up. We conclude that targeted hypothermia with neuromuscular blockade, as an adjunct to accepted techniques, may be an alternative for critically anemic patients with coronary artery disease refusing blood transfusion.

Rare case of concurrent intussusception and volvulus after Roux-en-Y gastric bypass for morbid obesity

Gastric bypass patients are at risk for small-bowel obstruction secondary to adhesions, internal hernias, intussusception and volvulus. Most gastric bypass patients do not present with classic obstructive symptoms. We present a rare case of concurrent intussusception and volvulus in a woman with previous history of internal hernia following laparoscopic Roux-en-Y gastric bypass surgery.

Can the laparoscopic approach for adhesive small bowel obstruction be used in octogenarians? An observational study using ACS NSQIP

BACKGROUND With the population of octogenarians projected to increase fourfold by 2050, we sought to compare outcomes of laparoscopic versus open approach in octogenarians requiring surgery for adhesive small bowel obstruction (SBO). METHODS/MATERIALS AND METHODS Using 2006-2015 American College of Surgeons National Surgical Quality Improvement Project, we identified patients aged ≥80 y who underwent emergency surgery within 1 d of admission for SBO. Risk variables of interest included age, sex, race, body mass index, preoperative sepsis, and American Society of Anesthesiologists (ASA) classification. Outcomes included length of stay, mortality, and pneumonia. Univariable and multivariable analyses were performed. RESULTS Eight hundred fifty-six patients were identified. Six hundred ninety-nine (81.7%) underwent laparotomy; 157 (18.3%) underwent laparoscopy. Twenty-four (15.3%) of laparoscopic cases were converted. There was no difference between the open and laparoscopic groups in age, and race, preoperative albumin, or preoperative sepsis. The open group had higher rates of totally dependent functional status, congestive heart failure, chronic obstructive pulmonary disease, and higher ASA class. There was no difference in operative time. Laparoscopy was associated with shorter length of stay. The open approach showed higher rates of postoperative pneumonia, myocardial infarct, and mortality. Multivariable analysis showed increased age, functional status, preoperative albumin, and ASA class associated with mortality. The operative approach was not associated with mortality. Postoperative pneumonia was associated with male sex and open approach. CONCLUSIONS Age, preoperative functional status, low preoperative albumin, and ASA classes IV and V were associated with mortality, while the open approach and male sex were associated with postoperative pneumonia. Octogenarians who present with SBO due to adhesive disease may benefit from an initial laparoscopic exploration. Further prospective studies are warranted.

Appendectomy in patients with human immunodeficiency virus: Not as bad as we once thought

Background. The number of patients living with human immunodeficiency virus and acquired immunodeficiency syndrome is growing due to advances in antiretroviral therapy. Existing literature on appendectomy within this patient population has been limited by small sample sizes. Therefore, we used a large, multiyear, nationwide database to study this topic comprehensively. Methods. Using the Nationwide Inpatient Sample, we identified 338,805 patients between 2005 and 2012 who underwent laparoscopic or open appendectomy for acute appendicitis. Interval appendectomies were excluded. We used multivariable adjusted regression models to test differences between patients with human immunodeficiency virus without acquired immunodeficiency syndrome and a reference group, as well as human immunodeficiency virus with acquired immunodeficiency syndrome and a reference group, with regard to duration of stay, hospital charges, in‐hospital complications, and in‐hospital mortality. Models were adjusted for patient age, sex, race, insurance, socioeconomic status, Elixhauser comorbidity score, and appendix perforation. Results. There were 1,291 (0.38%) patients with human immunodeficiency virus, among which 497 (0.15%) patients had acquired immunodeficiency syndrome. In regression analysis, human immunodeficiency virus alone was not associated with adverse outcomes, while acquired immunodeficiency syndrome alone was associated with longer duration of stay (incidence rate ratio 1.40 [1.37–1.57 95% confidence interval], P < .0001), increased total charges (exponentiated coefficient 1.16 [1.10–1.23 95% confidence interval], P < .0001), and increased risk of postoperative infection (odds ratio 2.12 [1.44–3.13 95% confidence interval], P = .0002). Conclusion. Patients with acquired immunodeficiency syndrome who undergo appendectomy for acute appendicitis are subject to longer and more expensive hospital admissions and have greater rates of postoperative infections while patients with human immunodeficiency virus alone are not at risk for adverse outcomes.