Patrick C. Bonasso

Supplements, nutrition, and alternative therapies for the treatment of traumatic brain injury.

Studies using traditional treatment strategies for mild traumatic brain injury (TBI) have produced limited clinical success. Interest in treatment for mild TBI is at an all time high due to its association with the development of chronic traumatic encephalopathy and other neurodegenerative diseases, yet therapeutic options remain limited. Traditional pharmaceutical interventions have failed to transition to the clinic for the treatment of mild TBI. As such, many pre-clinical studies are now implementing non-pharmaceutical therapies for TBI. These studies have demonstrated promise, particularly those that modulate secondary injury cascades activated after injury. Because no TBI therapy has been discovered for mild injury, researchers now look to pharmaceutical supplementation in an attempt to foster success in human clinical trials. Non-traditional therapies, such as acupuncture and even music therapy are being considered to combat the neuropsychiatric symptoms of TBI. In this review, we highlight alternative approaches that have been studied in clinical and pre-clinical studies of TBI, and other related forms of neural injury. The purpose of this review is to stimulate further investigation into novel and innovative approaches that can be used to treat the mechanisms and symptoms of mild TBI.

Resource savings and outcomes associated with outpatient laparoscopic appendectomy for nonperforated appendicitis

BACKGROUND Postoperative admission for acute appendicitis utilizes health care system resources. We evaluated outcomes and hospital charges for children with nonperforated appendicitis who underwent outpatient laparoscopic appendectomy. METHODS A retrospective chart review was performed for patients ≤18years old who underwent laparoscopic appendectomy for acute appendicitis in 2015. Patients were categorized into discharge from postanesthesia care unit (PACU) (outpatient), admission for <24-h, and admission for >24-h. Continuous variables were compared using analysis of variance and categorical variables were compared using chi-square test, with p<0.05 considered significant. RESULTS Of the 171 patients identified, 63 (37%) were discharged from the PACU, 94 (55%) were admitted <24-h, and 14 (8%) were admitted >24-h. There were no differences in postoperative emergency department/clinic visits, complications, or readmissions. Hospital charges for admission <24-h and >24-h were

Primary Colon Adenocarcinoma with Metastatic Disease to the Rectum Followed by the Left Axilla

1007 and

Small Bowel Obstruction Due to Suprapubic Catheter Placement

2237 more per patient than the PACU-discharge group, respectively. Outpatient laparoscopic appendectomies became more common over time, occurring in only 20% of patients with acute appendicitis in the first quarter of the year versus 49% of patients in the last quarter. CONCLUSION Outpatient laparoscopic appendectomy for nonperforated appendicitis in children is a safe practice that decreases length of stay and hospital charges. Adoption of an outpatient strategy allows for better standardization of care and can lead to savings in health care resources. LEVEL OF EVIDENCE III (Treatment: retrospective comparative study).

Feasibility of Cryopreserved Conduits for Complex Vascular Reconstruction in the Pediatric Population: The Case of a 3-Year-Old With Femoral Vessels Transections:

INTRODUCTION Adenocarcinoma of the colon can metastasize to multiple organs but very rarely metastasizes to the axilla. CASE We present a case of a 56-year-old male with metastatic colon adenocarcinoma that metastasized to the rectum and then the axilla. Three years after initial diagnosis and treatment of right colon mucinous adenocarcinoma a metastatic mass was found in the rectum. The mass was successfully resected, but within a year of finding the rectal mass, metastatic disease to the axilla was discovered. CONCLUSION This case provides valuable teaching points about routes of metastasis and the importance of continued clinical follow-up in patients diagnosed with adenocarcinoma of the colon.

Fatal Hyperammonemic Encephalopathy in a Pediatric Patient After Roux-en-Y Gastric Bypass

Suprapubic catheter placement has associated complications such as bowel injury, bladder injury, or bleeding. This case describes the management of an elderly patient who had suprapubic catheter placement complicated by small bowel obstruction. The catheter had continued production of urine. Further patient treatment required abdominal exploration and bowel resection.

Gallbladder varices in a pediatric patient after roux-en-Y gastric bypass

This report presents an unusual case of traumatic iliofemoral vessel transection in a 3-year-old patient successfully reconstructed using a cryopreserved greater saphenous conduit. Five years after injury, the patient continues to do well with normal ambulation. An arterial duplex demonstrated graft patency free of aneurysmal dilatation. These encouraging results suggest that the natural history of cryopreserved conduits may differ in the pediatric population and cryopreserved conduits could be used for complex vascular reconstructions.

24-hour and 30-day perioperative mortality in pediatric surgery

One third of children and adolescents in the USA are classified as either overweight or obese [1]. Moreover, 4.4 million children and adolescents have severe obesity [2]. There has been an increased volume of adolescent bariatric surgeries performed nationwide with reported cases doubled from 800 operations in 2003 to 1600 operations in 2009 [1, 3]. In adolescents, the most common procedure formorbid obesity is the Roux-en-Y gastric bypass (RYGB), accounting for 67.9% of cases [4]. The most common acute complications after RYGB include anastomotic leak, hemorrhage, early small-bowel obstruction, or incorrect limb reconstruction [5]. However, metabolic derangements such as metabolic acidosis or alkalosis, electrolyte abnormalities that may cause arrhythmias, and/or myopathies can occur. Additionally, nutritional abnormalities including fat-soluble vitamin, iron, folic acid, thiamine, vitamin B12, calcium, and vitamin D deficiency can also occur [6–9]. One rare but potent ia l ly fatal derangement is hyperammonemic encephalopathy (HAE). There have been less than 25 reported cases of HAE following bariatric surgery with a mortality rate of 50% [10–15]. We describe the first pediatric patient with HAE after successful RYGB.

Review of bedside surgeon-performed ultrasound in pediatric patients

This is a case with associated radiologic images for a pediatric patient who developed portomesenteric and splenic vein thrombosis (PMSVT) after Roux-en-Y gastric bypass with subsequent development of portal cavernoma and gallbladder varices (GBV). This case highlights both the importance of post-operative prophylactic anti-coagulation after gastric bypass and detailed imaging following a diagnosis of PMSVT. This case is relevant for pediatric surgeons as they are performing this operation more frequently with the increase in pediatric obesity.

Optimizing peripheral venous pressure waveforms in an awake pediatric patient by decreasing signal interference

PURPOSE The low perioperative mortality rate in pediatric surgery precludes effective analysis of mortality at individual institutions. Therefore, analysis of multi-institutional data is essential to determine any patterns of perioperative death in children. The aim of this study was to determine diagnoses associated with 24-hour and 30-day perioperative mortality. METHODS A retrospective review of the 2012-2015 Pediatric Participant Use Data File (PUF) was performed. Statistical comparisons were made between survivors and nonsurvivors and between those with 24-hour and 30-day mortality using Fischers exact tests. P-values ≤ 0.05 were considered significant. RESULTS 103,444 patients who underwent a pediatric surgical operation were evaluated. There were 732 deaths with a 30-day perioperative mortality of 0.7% (732/103,444). Necrotizing enterocolitis (NEC) was the diagnosis associated with the highest 30-day perioperative mortality (175/901, 19%). A significantly higher proportion NEC deaths occurred in the first 24 hours (67% (118/175) vs 33% (57/175) 30 day mortality, p<0.001). Compared to patients who survived following operation for NEC, those who died were statistically more likely to require inotropic support (56% vs. 15%, p<0.001), be diagnosed with sepsis (52% vs. 22%, p < 0.001), and undergo blood transfusion within 48 hours of operation (49% vs. 34%, p<0.001). CONCLUSION Although the overall pediatric surgical operative mortality rate is low, the largest proportion of perioperative deaths occur secondary to NEC. Based on the high immediate mortality, optimization of operative care for septic patients with NEC should be targeted. TYPE OF STUDY Prognosis Study LEVEL OF EVIDENCE: Level II.