I. Michael Leitman

Laparoscopic cholecystectomy for a left-sided gallbladder

Cholecystectomy is a common procedure. Abnormalities in the anatomy of the biliary system are common but an abnormal location of the gallbladder is much rarer. Despite frequent pre-operative imaging, the aberrant location of the gallbladder is commonly discovered at surgery. This article presents a case of a patient with the gallbladder located to the left of the falciform ligament in the absence of situs inversus totalis that presented with right upper quadrant pain. A laparoscopic cholecystectomy was performed and it was noted that the cystic duct originated from the right side. The presence of a left sided gall bladder is often associated with various biliary, portal venous and other anomalies that might lead to intra-operative injuries. The spectrum of unusual positions and anatomical gallbladder abnormalities is reviewed in order to facilitate elective and emergent cholecystectomy as well as other hepatobiliary procedures. With proper identification of the anatomy, minimally invasive approaches are still considered safe.

Hand sanitizer dispensers and associated hospital-acquired infections: friend or fomite?

BACKGROUND Waterless alcohol-based hand sanitizers are an increasingly popular method of hand hygiene and help prevent hospital-acquired infection (HAI). Whether hand sanitizer dispensers (HSDs) may themselves harbor pathogens or act as fomites has not been reported. METHODS All HSDs in the surgical intensive care unit of an urban teaching hospital were cultured at three sites: The dispenser lever, the rear underside, and the area surrounding the dispensing nozzle. RESULTS All HSDs yielded one or more bacterial species, including commensal skin flora and enteric gram-negative bacilli. Colonization was greatest on the lever, where there is direct hand contact. CONCLUSION Hand sanitizer dispensers can become contaminated with pathogens that cause HAI and thus are potential fomites.

Open repair of large abdominal wall hernias with and without components separation; an analysis from the ACS-NSQIP database

Background Components separation technique emerged several years ago as a novel procedure to improve durability of repair for ventral abdominal hernias. Almost twenty-five years since its initial description, little comprehensive risk adjusted data exists on the morbidity of this procedure. This study is the largest analysis to date of short-term outcomes for these cases. Methods The ACS-NSQIP database identified open ventral or incisional hernia repairs with components separation from 2005 to 2012. A data set of cohorts without this technique, matched for preoperative risk factors and operative characteristics, was developed for comparison. A comprehensive risk-adjusted analysis of outcomes and morbidity was performed. Results A total of 68,439 patients underwent open ventral hernia repair during the study period (2245 with components separation performed (3.3%) and 66,194 without). In comparison with risk-adjusted controls, use of components separation increased operative duration (additional 83 min), length of stay (6.4 days vs. 3.8 days, p < 0.001), return to the OR rate (5.9% vs. 3.6%, p < 0.001), and 30-day morbidity (10.1% vs. 7.6%, p < 0.001) with no increase in mortality (0.0% in each group). Conclusions Components separation technique for large incisional hernias significantly increases length of stay and postoperative morbidity. Novel strategies to improve short-term outcomes are needed with continued use of this technique.

Identifying Factors and Techniques to Decrease the Positive Margin Rate in Partial Mastectomies: Have We Missed the Mark?

Breast conservation therapy (BCT) has a reported incidence of positive margins ranging widely in the literature from 20% to 70%. Efforts have been made to refine standards for partial mastectomy and to predict which patients are at highest risk for incomplete excision. Most have focused on histology and demographics. We sought to further define modifiable risk factors for positive margins and residual disease. A retrospective study was conducted of 567 consecutive partial mastectomies by 21 breast and general surgeons from 2009 to 2012. Four hundred fourteen cases of neoplasm were reviewed for localization, intraoperative assessment, excision technique, rates, and results of re‐excision/mastectomy. Histologic margins were positive in 23% of patients, 25% had margins 0.1–0.9 mm, and 7% had tumor within 1–1.9 mm. Residual tumor was identified at—in 61 cases: 38% (disease at margin), 21% (0.1–0.9 mm), and 14% (1–1.9 mm). Ductal carcinoma in situ (DCIS) was present in 85% of residual disease on re‐excision and correlated to higher rates of re‐excision (p = <0.001), residual disease, and subsequent mastectomy. The use of multiple needles to localize neoplasms was associated with 2–3 times the likelihood for positive margins than when a single needle was required. The removal of additional margins at initial surgery correlated with improved rates of complete excision when DCIS was present. Patients must have careful analysis of specimen margins at the time of surgery and may benefit from additional tissue excision or routine shaving of the cavity of resection. Surgeons should conduct careful patient selection for BCT, in the context of multifocal, and multicentric disease. Patients for whom tumor localization requires bracketing may be at higher risk for positive margins and residual disease and should be counseled accordingly.

Perioperative care map improves compliance with best practices for the morbidly obese

BACKGROUND Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. METHODS A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. RESULTS In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. CONCLUSION After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.

The use of finger-stick blood to assess lactate in critically ill surgical patients

Background Using finger-stick capillary blood to assess lactate from the microcirculation may have utility in treating critically ill patients. Our goals were to determine how finger-stick capillary lactate correlates with arterial lactate levels in patients from the surgical intensive care unit, and to compare how capillary and arterial lactate trend over time in patients undergoing resuscitation for shock. Methods Capillary whole blood specimens were obtained from finger-sticks using a lancet, and assessed for lactate via a handheld point-of-care device as part of an “investigational use only” study. Comparison was made to arterial blood specimens that were assessed for lactate by standard laboratory reference methods. Results 40 patients (mean age 68, mean APACHEII 18, vasopressor use 62%) were included. The correlation between capillary and arterial lactate levels was 0.94 (p < 0.001). Capillary lactate measured slightly higher on average than paired arterial values, with a mean difference 0.99 mmol/L. In patients being resuscitated for septic and hemorrhagic shock, capillary and arterial lactate trended closely over time: rising, peaking, and falling in tandem. Clearance of capillary and arterial lactate mirrored clinical improvement, normalizing in all patients except two that expired. Conclusion Finger-stick capillary lactate both correlates and trends closely with arterial lactate in critically ill surgical patients, undergoing resuscitation for shock.

Association between elevated pre-operative glycosylated hemoglobin and post-operative infections after non-emergent surgery

Background A chronic state of impaired glucose metabolism affects multiple components of the immune system, possibly leading to an increased incidence of post-operative infections. Such infections increase morbidity, length of stay, and overall cost. This study evaluates the correlation between elevated pre-operative glycosylated hemoglobin (HbA1c) and post-operative infections. Study design Adult patients undergoing non-emergent procedures across all surgical subspecialties from January 2010 to July 2014 had a preoperative HbA1c measured as part of their routine pre-surgical assessment. 2200 patient charts (1100 < 6.5% HbA1c and1100 ≥ 6.5% HbA1c) were reviewed for evidence of post-operative infection (superficial surgical site infection, deep wound/surgical space abscess, pneumonia, and/or urinary tract infection as defined by Centers for Disease Control criteria) within 30 days of surgery. Results Patients with HbA1c < 6.5% and those with HbA1c ≥ 6.5% showed no statistically significant difference in overall infection rate (3.8% in the HbA1c < 6.5% group vs. 4.5% in the HbA1c ≥ 6.5% group, p = 0.39). Both linear regression and multivariate analysis did not identify HbA1c as an individual predictor of infection. Elevated HbA1c was, however, predictive of significantly increased risk of post-operative infection when associated with increased age (≥81 years of age) or dirty wounds. Conclusions The risk factors of post-operative infection are multiple and likely synergistic. While pre-operative HbA1c level is not independently associated with risk of post-operative infection, there are scenarios and patient subgroups where pre-operative HbA1c is useful in predicting an increased risk of infectious complications in the post-operative period.

Understanding the brain-heart axis in neurological trauma.

The cardiovascular physiologic effects of traumatic brain injury remain only partially understood. The autoregulatory manifestations of closed head injury have long been considered to be a catecholamine-mediated phenomenon [1]. Tachycardia, hypertension, coronary vasoconstriction resulting in cardiac ischemia, and arrhythmia have been attributed to sympathetic over activity [2]. However, these responses may not be physiologic [3]. Cardiac function is also regulated by baroreceptors, which are mediated by central paraganglionic neurons [4]. Activation results in a vagal-mediated bradycardia and a reduction in cardiac output. Trauma and central neurological injury may suppress this reflex [5]. The end result is in increased morbidity and mortality from neurologic injury, as it not only affects cerebral perfusion pressure but also cardiac afterload [6]. In addition, the complex relationship between PaCO2 arterial blood pressure results in changes in intracranial pressure that also affect intracranial dynamics and cerebral blood flow after neurological trauma [7]. This loss of the autoregulation has been associated with increased mortality [8]. Understanding these mechanisms is essential to improving patient outcome following traumatic brain injury. Are these phenomena due to complete interruption of the autonomic cardiovascular pathways or is this the result of other humoral mediators? Brain cytokine production may also play a role [9]. It appears that the severity of neurologic injury and outcome are inversely associated with heart rate and blood pressure. Others have shown direct evidence for cardiovascular and autonomic uncoupling in acute brain injury [10, 11]. This has led investigators to suggest that providing exogenous catecholamines and vasopressin would improve outcome [12]. On the other hand, others have suggested the use of b-blockers to reduce cardiovascular morbidity and mortality [13, 14]. In a paper recently published in the Journal of Surgical Research, Larson and co-workers have examined the scientific basis for hemodynamic changes following traumatic brain injury [15]. Their hypothesis suggests that the increase in catecholamines following closed head injury leads the generation of an increase in peripheral reactive oxygen species (ROS). This would result in cardiac injury. Their experiments assessed in vivo left ventricular ejection fraction using ECG-gated cardiac MRI, an increasingly utilized method to evaluate cardiac structure and function [16]. They were able to show that animals demonstrated a significant increase in systolic blood pressure following controlled traumatic brain injury. The difference between brain-injured rats and controls were hypercontractile left

Operative management of splenic rupture and hepatic flexure injury during diagnostic colonoscopy in a patient with adenocarcinoma of the cecum

Diagnostic colonoscopy has evolved to become the gold standard for the screening for carcinoma and other diseases of the colon. Injuries to the colon are rare and may be managed in a variety of ways. This includes observation and bowel rest or operative intervention and repair. Other organs are at risk during colonoscopy. The present report describes a patient who underwent colonoscopy for the work-up of anaemia. Following colonoscopy she developed signs of haemorrhagic shock and was found to have haemoperitoneum. She underwent surgery, and adenocarcinoma of the cecum was identified and managed during exploration. The clinical management is described.

The Iliad and the Odyssey of metallic foreign body extraction: commentary on "Novel methods of removing metallic foreign body from human soft tissue: a report of 7390 cases".

DOI of original article: 10.1016/j.jss.2012.1 * Corresponding author. Department of Surg Suite 2M, New York, NY 10003. Tel.: þ1 212 E-mail address: mleitman725@me.com (I 0022-4804/