Atrial Appendage Rupture Due to Blunt Trauma
Hassan Ahmed, MD, FICS, Chief Resident, Texas Tech University Health Sciences Center, Lubbock, TX
Several forces may perpetuate blunt cardiac injury including shearing from rapid
deceleration and compression of the heart between the spine and sternum.
6-10% of patients who suffer blunt chest injury also have cardiac
The case herein underscores the importance of rapid identification of this patient’s blunt traumatic cardiac rupture, enabled by expert use of the eFAST. It is also crucial to avoid inordinate attention to deformed extremity fractures. High index of suspicion and prompt identification using eFAST are key components of this patient’s successful outcome.
Embolization Of Bleeding Ileal Conduit Varices
Hassan Ahmed, MD, FICS, Surgery Resident, Texas Tech University Health Sciences Center, Lubbock TX
report with literature review. We present the case of a 55-year-old woman with
copious, recurrent ileal conduit bleeding from stomal varices. Bleeding was
successfully managed by PTEE. In view of absence of clinically significant other
varices or ascites, attempts were made to visualize the peristomal varices with
an 8-12 MHz linear array ultradsound probe Even though the presence of varices
around the stoma where established they were not accessible for cannulation. A
percutaneous transhepatic access to the right porta hepatis using AccuStick Kit
was obtained. This led access to the portal vein and from there to the superior
mesenteric vein. Venography confirmed the position of the varices, which then
were coil embolized successfully using Tornado coils time 6.
the successful coil emboiization, she was observed post procedure in the
hospital for 2 days, did not require additional blood transfusion. She was
discharged from the hospital in much better condition. The patient did not have
further bleeding or ischemic complications and has been event free for the last
Although rare, when a patient with ileal conduit stoma, hepatic dysfunction, and recurrent episodes of “macrohaematuria”¯, bleeding peristomal varices should be considered. Percutaneous transhepatic endovascular embolization is a reasonably good approach.
CNS Lymphoma: Analysis Of Treatment By Gamma- Knife Radiosurgery And
Chemotherapy In A Prospective, Observational Study
Andres M. Alvarez-Pinzon, MD, MSc, , Clinical Research Fellow, Neurological Surgery Department, Miami Neuroscience Center, Larkin Community Hospital, Plantation, FL
Primary central nervous system lymphomas (PCNSL) include 4% of all primary
brain-tumors. The dilemma posed by PCNSL treatment is the choice between
strategies designed to intensify therapy and strategies to avoid neurotoxicity.
The replacement of radiotherapy with other treatment modalities is an
alternative approach that has also been well studied. This is a clinical study
reporting the Gamma knife radiosurgery-(GKRS) experience in patients with
Primary CNS lymphoma.
Prospective, observational study evaluating the radio-surgical treatment
of PCNSL. Strict inclusion and exclusion criteria were employed. Primary
outcomes were the presence or absence of a lesion in a previously treated zone.
Secondary outcomes were survival rate, patients’ satisfaction and
quality of life (QOL).
Between January 1998 and January 2015 thirty-four patients were treated with
doses ranging from 12 Gy to 26 Gy (median:13.8Gy).
Fifty percent isodose line (range:45-85). Treatments in
14 of the 34 patients had failed chemotheraphy prior to GKRS; 4 patients
were managed with only biopsy and GKRS. None of the patients showed any
deterioration in their QOL related to the treatment and no complications were
reported after the procedure. All lesions showed a complete response when
evaluated using magnetic resonance imaging 3-8 weeks (mean range 6.3 weeks).
Median survival was 46.3months from the initial diagnosis and 42months after
Conclusions: The use of GKRS is non-invasive, safe, and shows rapid success, improving the prognosis and QOL of the patient. This noninvasive treatment modality should be considered as an option for patients with Primary CNS lymphoma.
Mission Surprises - Honduras 2015
Domingo Alvear, MD, FICS, Pediatric Surgeon, Pinnacle Health System, Harrisburg, PA
From A Meckel's Diverticulum - 35 Years Experience
Domingo Alvear, MD, FICS, Pediatric Surgeon,Pinnacle Health System, Harrisburg, PA
Guided Placement of high Activity, Low Dose Rate (HALDR) Brachytherpay Seeds
Hassan Anbari, MD, Radiology Resident, Providence Hospital, Southfield, MI
Radioembolization For Non-Resectable Primary And Metastatic Liver Cancer
Hassan Anbari, MD, Radiology Resident at Providence Hospital, Southfield, MI
and Mortality in Adults Undergoing Resection of
Ahmed Awad, MD, Post-doc Research Associate, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY
Meningioma is the most common benign brain tumor. In this study, we focus on the
morbidity and mortality associated with supratentorial meningioma surgeries in
A retrospective study of a prospectively collected data utilizing the American
College of Surgeons National Surgical Quality Improvement Project (NSQIP)
database. Inclusion criteria were adult patients (= 18 years) who underwent
resection of supratentorial meningioma between years 2005 to 2012.
A total of 1,568 patients were identified. The morbidity and mortality rates
were 21.2% and 1.7%, respectively. The most common morbidity complications were;
peri-operative blood transfusion (POBT), on ventilator >2 days, urinary tract
infections (UTIs), DVT/thrombophlebitis, stroke/CVA, unplanned intubation,
pulmonary embolism (PE), sepsis, and wound complications. Cardioplumonary and
CNS complications, UTIs, POBT, DVT/PE and sepsis were all significant
(P<0.05) predictors of mortality. On the other hand, return to OR, extended
hospital stay (>30 days), unplanned reoperations and admissions were all
significant (P<0.0001) predictors of morbidity. On multivariate analysis, age
(>50 years), functional status prior to surgery, were all significant
(P<0.05) predictors of both morbidity and mortality. In addition, pulmonary
and renal comorbidities, recent weight loss, pre-operative blood transfusion,
and operative time >4 hours were significantly (P<0.05) associated with
high risk of morbidity.
Meningioma resection is associated with relatively high risks of morbidity and
mortality. Patients >50 years should be given special consideration.
Maintaining operative time <4 hours and decreasing pre-operative blood
transfusion may decrease the risk of morbidity.
Ionizing Radiation in Pediatric Emergency Department Patients with Suspected
Liisa Bergmann, MD, Radiology Resident, PGY-3 / R2, Royal Oak, MI
evidence suggests that the ionizing radiation associated with computed
tomography (CT) in pediatric patients is also associated with long-term negative
health sequelae. Our immediate
purpose is to evaluate changes in ordering frequency of ultrasonographic
examination (US) and CT in pediatric emergency department (PED) patients with
suspected appendicitis in a community setting.
This is within the context of the long-term goal of attaining ionizing
radiation “as low as reasonably achievable.”¯
Retrospective review of all PED patients who underwent abdominal US and/or CT Abdomen / Pelvis (CTAP) was performed. Charts were reviewed for one year prior to and one year following the implementation of an electronic medical record (EMR) prompt reminding physicians ordering CT Abdomen / Pelvis in PED patients with suspected appendicitis to first order US. Multivariate regression analysis was performed.
results suggest that although the likelihood a US examination would be performed
on a PED patient with suspected appendicitis increased to nearly 100% after the
implementation of the EMR prompt, CT was also ordered for nearly all patients.
It is well known that US is highly user dependent and the appendix is frequently not visualized on US examination. Our data suggest that US examination alone does not preclude the need for additional information for diagnosis, nor does US examination significantly reduce ionizing radiation exposure in PED patients with suspected appendicitis. Our findings support development of a standardized physical exam protocol developed and accepted by surgeons and emergency physicians in order to achieve ionizing radiation ALARA.
Endovascular Treatment of Ischemic Stroke
W. Craig Clark, MD, PhD, FICS, AANOS Interim Chairman, Attending Neurosurgeon, Greenwood-Leflore Hospital, Greenwood, MS
Invasive Surgical(MIS) Techniques for the Management of Spinal Metastases
W. Craig Clark, MD, PhD, FICS, AANOS Interim Chairman, Attending Neurosurgeon, Greenwood-Leflore Hospital, Greenwood, MS
Open surgical treatment has a well- established track record in the treatment of these patients. More recent advancements in surgical technique, instrumentation and imaging modalities have evolved into minimally invasive surgical (MIS) techniques that have now been adapted to the treatment of metastatic disease to the spine. It is felt that the use of MIS may minimize the overall degree of physiological insult to the already compromised patients, and may allow quicker adjuvant chemotherapy or radiotherapy than would have otherwise been possible with the more established open procedures. The current study reviews the techniques currently used in MIS of metastatic disease to the spine, and attempts to delineate the more appropriate (or inappropriate) application of these techniques.
of Newer Anticoagulants for the Surgeon
Edward Danielle, MD, PhD, FICS, Resident, Texas Tech University Health Sciences Center, Lubbock, TX
Surgeons are increasingly challenged by patients taking non-Vitamin K antagonist
anticoagulants for cardiac arrhythmias and thromboembolism prevention. These
newer oral anticoagulants consist of Factor Xa inhibitors and direct thrombin
inhibitors. Compared to Warfarin, these medications decrease risk for stroke,
embolism, hemorrhagic stroke, major bleeding, and death. Unfortunately, these
newer agents often have no antidote, sometimes posing significant threat to the
patient. Herein we summarize anticoagulant medications and their mechanisms,
antidotes and duration of action.
Three major trials have prompted increased use of the newer anticoagulants,
including the ARISTOTLE trial, the RE-LY trial, and the ROCKET-AF trial. Herein
we review these studies and their application to the surgical patient.
Regardless of the class of anticoagulant, the first step is to stop the
medication immediately. For patients who have ingested the anticoagulant within
the previous two hours, the next step is activated charcoal. The third step
depends upon the drug consumed. If
the patient is taking a direct thrombin inhibitor, 1g of tranexamic acid (TXA)
may be given. Additionally, the patient should be aggressively hydrated since
only 35% is protein bound and the drug is excreted primarily through the
kidneys. Hemodialysis may be
performed. In the setting of
unstable hemorrhage, FEIBA (Factor 8 inhibitor bypass activity) may be given.
FEIBA is the only clinically approved activated PCC (prothrombin complex
on Rivaroxaban should receive 4-Factor PCC. If refractory bleeding persists,
FEIBA may be used. A similar
protocol can be followed if the patient ingested a factor Xa inhibitor.
Conclusions: The number of patients taking new anticoagulants will continue to increase. The surgeon's knowledge of mechanism, duration of action and reversal strategies are crucial for successful treatment.
for Health Care Professionals
Vilma Drelichman, MD, FACP, FIDSA, Clinical Professor Wayne State University, Detroit, Michigan, Southfield, MI
workers are at increased risk of contracting infections at work, and further
transmit them to colleagues and patients.
audience needs to know that protecting themselves act as a barrier against the
spread of infections and maintain healthcare delivery during outbreaks.
audience will learn why mandatory vaccination policies are occasionally
implemented by healthcare authorities and how to implement such policies.
The audience will learn the importance of HCW vaccination, in particular those working with high risk individuals.
of Medical or Surgical Admission on Outcomes of Patients with Acute
Cholecystitis: A Multivariate Regression Model
Joseph Eid, MD, General Surgery resident, Providence Hospital and Medical Center, Michigan, Southfield, MI
Between July 2010 and March 2013, 329 consecutive patients younger than 70 years
old presented to a community-based academic tertiary care hospital with AC.
Primary outcomes included hospital length of stay (LOS), time to cholecystectomy,
hospital costs, readmission and mortality rates.
Two hundred fifteen patients (65.3%) were admitted to the medical service during
the study period. Patients admitted to the surgical service were significantly
younger (41.5 years ± 12.9 vs. 47.9 years ±13.1, p<0.001). On multivariate
logistic regression analysis controlling for patient’s characteristics, the
patients under the medical service had longer LOS (4.4 days ± 3.7 vs. 2.9 days
± 2.1, p=0.03), waiting time to cholecystectomy (1.8 days ± 2.6 vs. 0.86 days
± 1.1, p=0.007) and increased hospital costs ($5654.79 ± $3282.28 vs. $4323.53
± $2498.64, p=0.03) as compared to surgical group. Readmission and mortality
rates were not significantly different between groups.
CONCLUSIONS: Patients younger than 70 years old with AC undergoing cholecystectomy admitted to a medical service had a longer time to operation, LOS and increased hospital costs compared to those admitted to a surgical service. Admission to a surgical service for patients with a surgical diagnosis needs to emphasized to reduced cost and improved quality.
Cleaning After Placental Delivery At Cesarean Section: A Randomized Controlled
Ahizechukwu Eke, MD, MPH, FICS, PGY4 Obstetrics & Gynecology Resident, Clinical Instructor, Michigan State University, Lansing, MI
randomized 206 women undergoing primary elective cesarean deliveries to cleaning
(103 women) or omission of cleaning (103 women) of the uterine cavity after
placental delivery. Spontaneous rupture of membranes prior to cesarean section,
chorioamnionitis, poorly controlled diabetes mellitus, patients on chronic
steroid therapy and patients with immunosuppressive disorders were excluded.
Primary outcome measure was postpartum endomyometritis. Secondary outcomes were
postpartum hemorrhage, mean surgical time, retained products of conception,
quantitative blood loss, length of hospital stay, return of gastrointestinal
function, repeat surgery and hospital readmission rates. Analysis followed the
There were no statistically significant differences in the rate of endomyometritis between those who received intrauterine cleaning and those who did not (2.0 vs. 2.9%; RR = 0.60; 95% CI 0.40-1.32). No retained products of conception occurred in either group, and there were no statistically significant differences in postpartum hemorrhage (5.8% vs 7.7%, RR 0.75, 95% CI 0.6-1.2), hospital readmission rates (2.9% vs 3.8%, RR 0.75, 95% CI 0.8-1.5), mean surgical time, hospital length of stay, return of gastrointestinal function, repeat surgery, and quantitative blood loss between both groups.
Our randomized controlled trial provides evidence suggesting that in women at low risk for infection, omission of intrauterine cleaning during cesarean deliveries does not increase intraoperative or postoperative complications.
in the Current Management of Stroke
Richard Fessler, MD, Chairman, Department of Surgery, St. John Hospital & Medical Centers
Medical Director, Ascension of Michigan Telemedicine Oversight Committee, Detroit, MI
is the fourth leading cause of death and the number one cause of adult
disability in North America. In-hospital
and peri-procedural stroke is a common occurence. Up to 40% or more of
in-hospital strokes may occur in patients on surgical or other procedural
of care for victims of stroke is time dependent.
Thus, it is important that the practicing surgeon or proceduralist
recognize signs of stroke and be aware of new modalities for the potential
treatment of patients suffering an in-hospital ischemic event.
participating, the audience will:
be able to discuss the latest interventional treatment techniques for acute
2) learn the most common causes of acute stroke;
3) generate a potential differential diagnosis for peri-procedural stroke;
4) be able to discuss the recent major studies regarding acute stroke treatment;
5) recognize their local resources for management of acute stroke.
Hepatobiliary and Pancreas Surgery in a Minimally Invasive Era
Michael Jacobs, MD, FICS, Associate Chair of Surgery, HPB Program and HPB Surgery Fellowship Director
St. John Providence and Providence Park Hospitals, Southfield and Novi, MI
To provide knowledge and innovative technical exposure based on 15-years
of experience in the field of HPB Surgery through video-based education.
Hepatobiliary and pancreas surgery involves complex learning curves.
Traditionally, an open technique was used, but laparoscopic HPB surgery
is gaining wider acceptance. Complex
laparoscopic HPB surgery provides
all of the advantages of laparoscopic techniques without compromising the
outcome. This lecture reviews the
indications, contraindications, and technical approach through a video-based
education format, enabling the viewer an opportunity to understand the various
technical pearls and pitfalls.
and Methods: The cases presented
will demonstrate the laparoscopic approach to common HPB problems based upon the
authors experience. Clinical
vignettes will be used to review pertinent data that focus on anatomic
approximation of relevant structures and suitability for a laparoscopic
The technical video demonstrates the totally laparoscopic complex HPB
Surgery. Selected highlighted
procedures, pearls, and pitfalls are reviewed.
The postoperative outcomes will
Totally laparoscopic HPB surgery is technically feasible and affords the
patient all of the benefits of laparoscopic surgery without compromising the
and Cost Effectiveness of Iliac Stenting in the Operating Room and Cath Lab
Sooyeon Kim, BS, Medical Student, University of Kentucky, Lexington, KY
arterial stenting is routinely performed both in the operating room (OR) and in
the catheterization lab (CL). To date, no analysis has been conducted to compare
efficacy and resource utilization between these locations.
Consecutive patients (N=105) treated between 2006 and 2013 at a single center were retrospectively analyzed. Patients included adults with chronic, symptomatic iliac artery stenosis with a minimum Rutherford Score (RS) of 3. Patients were treated with stents of the unilateral or bilateral external iliac, internal iliac, or aortoiliac arteries. Exclusion criteria were prior stenting, acute ischemic presentation, or major concomitant procedures. Patient demographics, procedure details, hospital course, physician billings, and actual procedure room and total costs were recorded, the latter from the hospital cost accounting system. All variables were compared by procedure location. Multivariable regression was used to adjust costs by demographic and perioperative cost drivers. Immediate outcomes included technical success, length of stay, same-stay reintervention, and major complications. Two-year outcomes included reintervention, death, or loss to follow-up.
Fifty-one procedures (49%) were performed in the OR and 54 (51%) in the CL. Mean age was 57 and 44% were female. Diabetes (DM) was more prevalent in OR patients (49 vs. 26%, p=0.016), and hyperlipidemia (HLD) in CL patients (80 vs. 57%, p=0.020). DM and elevated creatinine were associated with increased total costs; HLD with increased procedure room costs. Severe cases (RS = 4) were more often performed in the OR (42 vs. 11%, p<0.001) and were associated with increased total costs (p<0.01). OR procedures more often utilized additional stents (stents = 2; 61 vs. 46%, p=0.214), thrombolysis (12 vs. 0%, p=0.011), cut-down approach (8 vs. 0%, p=0.052), and endotracheal anesthesia (80 vs. 0%, p<0.001): these were all associated with increased costs (p<0.05). There was no difference in procedure room costs (OR median $7,700 vs. $8,300, p=0.445) but OR procedures were associated with increased total hospital costs (OR median $13,500 vs $9,100, p<0.001). OR procedures also resulted in increased hospital length of stay (LOS > 1 day; 41% vs. 17%, p<0.01) and more often required admission to the ICU (37 vs. 2%, p<0.001). Subsequent multivariable regression revealed that OR location was not a predictor of either procedure room or total costs, but was associated with increased professional fees (exponentiated coefficient for log-transformed procedure room costs 0.95, 95% CI 0.89-1.02; total costs 1.09, 95% CI 0.98-1.21; physician billings 1.31, 95% CI 1.13-1.51). Same-stay reintervention (4.8%) and reintervention after discharge (33%, median follow-up 13 mos.) did not vary by location.
Stenting performed in the OR resulted in increased LOS, more frequent ICU admission, and ultimately increased total costs. However, patients brought to the OR had more severe disease at presentation and therefore often required more aggressive intervention. After controlling for these differences, procedure venue per se was not associated with increased costs but the OR was associated with increased professional fees. Given the similar outcomes between venues, it would therefore seem reasonable to perform most stenting in the CL, while judiciously sparing the OR for more severe cases.
Of Large Acoustic Neuromas
Michael LaRouere, MD, President, Michigan Ear Institute, Director of Neurosciences, Providence Hospital and Medical Center, Clinical Associate Professor, Wayne State University,
Clinical Professor, Michigan State University, Clinical Professor William Beaumont/Oakland University, Farmington Hills, MI
The treatment of large acoustic tumors is very challenging. Preservation of facial nerve function in tumors measuring 3 cm or greater has averaged 49% following surgical removal over the past few decades. Utilizing a staged approach to tumor removal has resulted in a 79% chance at good facial nerve function postoperatively. A retrospectiver eview of 2875 acoustic neuroma patients over a 10 year period was undertaken. One hundred fifty three large (>3cm) AN patients who were operated upon were identified.Staged surgical patients were compared to those undergoing single stage surgery with or without adjuvant stereotactic radiosurgery with respect to post treatment facial nerve function. Eighty one percent of patients in the staged surgical resection group had HB grade I-II facial functioncompaired with 75% in the single stage group Overall 79% of patients had good (HB I-II) facial function compaired to those studies in the literature showing 49% good facial function following resection of AN tumors over 3 cm. The audience will learn our methods, including staged resection, the use of facial nerve monitoring and a team approach to skull base surgery which have led to improved outcomes with these challanging cases.
Brachial Plexus Injury Secondary to Inappropriate Positioning Among Adults
Rana Latif, MD, FCAI, FICS, Associate Prof., Dept of Anesthesiology & Perioperative Medicine, Anesthesiology and Neuroscience Critical Care, University of Louisville, Louisville, KY
The prevalence of iatrogenic brachial plexus injury (BPI) has been estimated at 0.02-0.06%, represents 23% of nerve injuries claims but 35% received substandard care. The BPI is caused by stretching and compression of nerve leading to ischemia of the nerve adding postoperative morbidity. The positioning of the patient in the operating room can be divided into four stages with different physician responsible for correct position. These stages are (1) preoperative: anesthesiologist; (2) intraoperative: surgeon; (3) intraoperative change of positioning: surgeon and (4) postoperative: anesthesiologist. A team approached is required with respect to positioning of these patients. The first step is to identify the high risk patients for BPI preoperatively. These include patients with diabetes mellitus, hypertension, pre-existing neuropathy, peripheral vascular disease, obesity, arthritis, smoking with COPD, cervical rib, deformity of the shoulder region (e.g. post trauma) and anomalous origin of brachial plexus. Intraoperative causes included prolonged operating time, median sternotomy, hypothermia and hypotension. The certain positioning can increase the risk of BPI including excessive abduction of the arm (> 90?), steep Trendelenburg with shoulder braces, external rotation of the arm, excessive rotation of the head and dorsal extension at shoulder. The surgical units should develop written positioning standard, communicate them to different specialties, professionals and staff. They should have sufficient padding and positioning materials for surgeries. It is important to document that during the surgery, the positioning standard were maintained. If BPI occurs, determine the extent of injury with sensory and motor deficit. Develop plan of care with involvement of patient, patientsā€™ family, neurologist and physiotherapist. The patient should be followed up with documentation of neurological recovery. Fortunately, in most of the cases, the recovery is complete.
Invasive Outpatient Treatment of Degenerative Spine Pathology
Miguel Lis-Planells, M.D., Neurosurgeon, The Bonati Spine Institute, Hudson, FL
Bonati Spine Institute in Hudson, Florida has been a center of excellence in the
growing field of outpatient minimally invasive spine surgery for over 20 years,
pioneered by its founder Dr. Alfred Bonati. This vast experience allows us to
offer our patients a success rate of over 95%, measured as significant reduction
or elimination of pain, with a complication rate of less than 1% for the
treatment of a large variety of pathology affecting the spine.
Collectively, our techniques have been known as the Bonati Procedures.
our presentation, The Bonati Procedures for the outpatient treatment of spinal
pathology using minimally invasive surgical techniques will be discussed, which
include the following aspects:
Careful patient selection.
- Customized surgical plan specifically designed for each patient.
- Meticulous, state of the art, minimally invasive surgical procedures that involve the use of patented instruments, surgical and anesthesia techniques that have been developed at our Institute.
- Methodic perioperative care provided to our patients, ensuring an optimal surgical outcome.
overview of the main indications and contra-indications for the application of
the Bonati Procedures will be
presented. Illustrative cases of
patients treated at the Institute will be discussed and surgical outcomes will
be shown, including early return to work , minimal use of post operative
narcotic medication and shortened recovery and return to activities of daily
In conclusion, The Bonati Procedures utilize state of the art, minimally invasive patented surgical technology that proves to be safe and effective for the treatment of degenerative spinal pathology in the outpatient setting and offers our patients high surgical success, low post-operative complication rate and improved patient outcomes.
Sharique Nazir, MD, FICS, Surgery Attending, NYU Lutheran Medical Center, New York, NY
loss surgeries are one of the
fastest growing hospital procedures performed in the United States. It is
estimated that 220,000 weight-loss surgeries were performed in 2008 .
following surgical treatment of severe obesity vary based upon the procedure
performed and can be as high as 40 percent . Due to the high surgical volume,
improving the safety of these operations has become a high priority, leading to
the development of strict criteria for center accreditation, guidelines for safe
and effective bariatric surgery, and careful monitoring of surgical outcome.
or metabolic surgery is the only proven long term approach to reduction of
obesity comorbidities and significant weight loss. It is however a relatively
new branch of surgery one that has complex and variable anatomy that some
general surgeons may not be familiar with. The number of bariatric surgeries
performed has remained stable yet the incidence of complications is rising due
to a rising percentage of the population that are former bariatric patients. The
risk of complications does not diminish as the time from the index operation
passes and as it becomes more remote the chances that they will present
emergently to a non-bariatric center for care of by a general surgeon increases.
There is also a rise in surgical tourism for low cost weight loss surgery which
can result in visits very soon post operatively and without full knowledge of
what was done or the quality of the work. The general surgeon's needs to be
familiar with the varied complications of bariatric surgery so that he can
triage which patients need urgent intervention
and which patients need referral to a bariatric center. After this
presentation the audience will familiar with the common complications of
bariatric surgery, how they present, their proper workup and radiological
presentation and their common treatments.
The audience should be familiarized so they can diagnose and manage symptoms.
Seton For High Anal Transsphincteric Anal
Petar Petricevic, MD. PhD, FICS, Consultant Colon and Rectal Surgery, Zrenjanin, Serbia
No single procedure for high anal transsphincteric
fistula delivers a high cure rate while also completely protecting
sphincter function. Our aim is to present our experience
and results with thightening ligation
of intersphincteric fistula track procedure.
Between 1995 and 2011 year we are operated twenthy patients
with high cryptoglandular fistulae when
more than one-third of the sphincter is involved and we treat these patients
in mayority in nineteen patients with ligation of intersphincteric
fistula track (LIFT) or cutting seton.
In one patient with
recurrence after fistulotomy, which was first
operated on a second surgeon , after our operation (LIFT), we have
had completely healing, but the patient received minor soiling
incontinence. In small number of three femail patients , in two cases we
are treated with thightening cutting
seton (LIFT) procedure and in one femail patient
with fistulae on anterior commissure,
we are treated with primary repair of external sphincter,
and in all three femail cases we are not notice problems with healing,
continence and FIQL. In other 16
male patients we have had one
patient of this 16 patients with supralevator
extension and other one patient had extrasphincteric
fistula secondary to transsphincteric
fistula. In all 16 cases we used to
put thightening cutting seton and in
this group of patients, we have had satisfied healing without recurrence,
overall change in bowel control and FIQL.
SUMMARY: Cutting seton for high anal fistula achieved excellent healing, good continence in majority, particularly in males, and high level of patient satisfaction.
Management Of Patients With Colorectal Cancer And Synchronous Liver Metastasis
Or Indeterminate Liver Lesions: A Retrospective Review
Sunu Philip, MD, FICS, General Surgery Resident, Providence Hospital and Medical Centers, Southfield, MI
Between a third to one-half of patients with colorectal cancer develop liver metastases . Approximately 15-25% of these patients present with one or more liver metastases at the time of diagnosis. The management of patients with synchronous colorectal metastases limited to the liver remains controversial with much of thedata published from highly specialized academic centers. We proposed to review the management and outcomes of patients with colorectal cancer and synchronous liver metastases at a community teaching hospital.
In this institutional review board approved retrospective study, the medical records of all patients with a diagnosis of colorectal cancer identified in the cancer registry of the hospital were reviewed. The review was conducted over a five year period from 2008-2013. The study sample included all patients with a primary diagnosis of colorectal cancer and synchronous liver metastases who had undergone a colon or rectal resection. We also reviewed the records of all patients who had an indeterminate lesion noted on preoperative staging and then progressed to have liver metastases on follow up imaging after their colon resection. A total of 811 patients with colon or rectal cancer were entered in the cancer registry over the study period. Ninety patients met the criteria for inclusion in the study. This sample was divided into three subgroups based on the pattern of their liver metastases. Patients with diffuse bi-lobar disease were classified as multiple, those with a finite number of metastatic deposits were classified as discrete. Finally those those patients with indeterminate lesions that progressed to cancer were classified as indeterminate.
Of the 90 patients, 50(55%) had diffuse metastatic disease at diagnosis. Twenty
five patients (27%) had discrete lesions and 15 (16%) had indeterminate lesions.
Twenty seven patients in the diffuse group had presented with intestinal
obstruction and had emergent colon surgery. Only 4 patients in this group were
treated with primary chemotherapy. One patient in this group had a resection of
hepatic metastases. In the discrete group, the number of liver secondaries
ranged between 1 and 4 lesions with a size ranging between 0.9 and 7 cm. Ten of
the 25 patients in this group had liver resections of which 4 were done
synchronously at the time of their colon surgery. Only two patients in the group
with indeterminate lesions had a liver resection. The time to liver resection in
those patients who staged procedures ranged from 4 months to two years from
their colon surgery. Progression of disease was noted in all patients with
diffuse disease on serial imaging and in a large number of patients with
discrete and indeterminate lesions who were treated without hepatic resection.
Of the 90 patients, 50(55%) had diffuse metastatic disease at diagnosis. Twenty five patients (27%) had discrete lesions and 15 (16%) had indeterminate lesions. Twenty seven patients in the diffuse group had presented with intestinal obstruction and had emergent colon surgery. Only 4 patients in this group were treated with primary chemotherapy. One patient in this group had a resection of hepatic metastases. In the discrete group, the number of liver secondaries ranged between 1 and 4 lesions with a size ranging between 0.9 and 7 cm. Ten of the 25 patients in this group had liver resections of which 4 were done synchronously at the time of their colon surgery. Only two patients in the group with indeterminate lesions had a liver resection. The time to liver resection in those patients who staged procedures ranged from 4 months to two years from their colon surgery. Progression of disease was noted in all patients with diffuse disease on serial imaging and in a large number of patients with discrete and indeterminate lesions who were treated without hepatic resection.
Only a small proportion of patients with synchronous colorectal liver metastases are candidates for a potentially curative resection. In this series only a small proportion of patients with diffuse unresectable metastatic disease were treated with primary chemotherapy. Patients with localized disease should be evaluated early for synchronous or early staged resection. Patients with suspicious indeterminate lesions may benefit from evaluation of these at the time of their of colon resection or alternatively will need careful followup imaging.
Associated With Treatment Failure After An Index Episode Of Acute Diverticulitis
Sunu Philip, MD, FICS, Resident, General Surgery, Providence Hospital and Medical Centers, Southfield, MI
after a first episode of diverticulitis are reported to occur in up to 40% of
patients. Sigmoid resection has traditionally been recommended after 2 episodes
of uncomplicated diverticulitis. Factors that have been reported as associated
with recurrence are a prior history of diverticulitis, abscess and
corticosteroid medication use. Recurrence occurs at any time period after
successful resolution of the index episode. We have however observed patients
who do not completely recover from their index episode. This purpose of this
study was to investigate the factors associated with treatment failure after an
index episode of acute diverticulitis.
A retrospective review of all patient readmitted to hospital within 120 days of an index episode of Hinchey stage 1 and 2 diverticulitis was conducted over a period from 2008-2014. Demographic data, important co-morbidities, body mass index(BMI) and outcome at most recent available followup were recorded. Data on antibiotic type and duration, percutaneous drainage and progression of disease based on repeat computed tomography (CT) imaging was also recorded on those patients were this data was available. Important inclusion criteria were the presence of an index episode of Hinchey stage 1 or 2 diverticulitis based on CT imaging and a readmission or emergency room visit within a 120 days with repeat CT imaging documenting persistent or progressive disease.
One hundred patients were identified who met criteria for inclusion in the study. Sixty seven (67%) were female and 33 (33%) were male. The average age of the population was 63 (33-91) with a median of 60 years. Seventy seven patient (77%) had Hinchey stage 1 diverticulitis at their index presentation while 23 (23%) had stage 2 disease with a pericolic abscess. Twelve patients (12%) had been treated with oral antibiotics prior to their presentation to hospital. Fifteen patients (15%) received drainage or aspiration of a pericolic abscess during their index admission. The median time to readmission was 30 days (3-120 days). Thirty one patients (31%) were smokers and the median body mass index (BMI) of this sample was 30kg/m2 with an average of 31.2kg/m2. Sixty two patients (62%) had progression of their disease based on repeat imaging. Seventy one (71%) patients had a sigmoid colectomy in this series.
At least 50% of patients in this series who had persistent diverticulitis after their index admission had a BMI higher than 30kg/m2. In addition over 70% of patients with persistent disease received a sigmoid colon resection. The findings of this study suggest that obesity may be associated with treatment failure after an index episode of uncomplicated diverticulitis and that persistent disease despite adequate medical therapy is associated with the need for eventual sigmoid resection.
Disturbingly High Cost of Your Career in Surgery:
The Business of Medicine in 2016 from the Perspective of a Tax Attorney, Business Owner, and Doctor Advocate
Victoria Powell, JD, LLM (taxation), Medical Education Speaker's Network: Victoria J. Powell JD, LL.M LLC, owner; Powell Heymann LLC, partner, Scottsdale, AZ
Per Becker’s Hospital Review, surgeons occupy fifteen out of the top 25 earning medical specialties, with Orthopedic and Neurosurgeons ranking first and second, according to Merritt Hawkins’ 2014 Review of Physician and Advanced Practitioner Recruiting Incentives. These statistics rank surgeons among the “top 1%” of all US income earners - a space they share with the wealthiest families in America, but unlike those families (whose money earns money), surgeons earn ordinary income and pay tax at the highest rates. While this income level is a tremendous career accomplishment, not surprisingly, many surgeons do not have sufficient knowledge, experience or skills to understand that they may inadvertently be losing money in not being prepared to fully address practice management issues and risks, especially in a fast-changing financial environment, in overpaying taxes year after year, and in investing in complex retirement or insurance plans, or medical real estate without adequate business analysis tools. This seminar will help close that educational gap, not only by providing a tax attorney’s perspective on these issues, but also by learning from those that have actually lost money by discussing de-identified client case studies. Background information on the tax laws, health care law, Treasury regulations, IRS enforcement patterns and case law that govern highly compensated individuals and corporate entities will lay the foundation for the discussion. Case studies will be presented as ‘what not to do’ examples. Lastly, ‘what to do’ strategies and tactics will be presented on practice management concepts and coordination of professional service providers, how to use the health care and tax regulations for better results, and how to control ‘controllable’¯ risks to help keep more hard earned money, as well as how to recover and improve the surgeon’s autonomy in practice, employment and even, perhaps, politics.
of Inguinal Hernias in Premature Infants - Pre or Post discharge? - What is
Farda Qayyum, MD, Surgical Resident, Pinnacle Health System, Harrisburg, PA
The purpose of this retrospective study is to determine the optimal management
of inguinal hernias in premature infants, including timing of repair as well as
type of anesthesia. Premature Infants of both sexes have a higher incidence of
inguinal hernia than full term infants. They are being discharge from the
hospital as long as they are feeding and have no respiratory issues. Their
weight upon discharge has been between 2 to 2.5 kg. We have proven that hernia
repair under regional anesthesia (spinal or caudal) is safer than general
anesthesia. Infants can be discharged within 24 to 48 hours post operatively.
Sending them home post repair will prevent the potential complications of
inguinal hernias including incarceration or strangulation and feeding
Premature infants undergoing inguinal hernia repair during initial
hospitalization with caudal blocks will have a smaller recurrence rate as well
as fewer complications.
A retrospective chart analysis will be performed on premature infants who have
undergone inguinal hernia repair in a 20-year period at our institution. Hernia
repairs at our institution are generally performed during the sentinel
hospitalization. An open technique is employed with regional anesthesia (spinal
or caudal). Complications including hernia recurrence, wound complications and
anesthesia complications will be assessed. We will compare out complication
rates with those cited in current literature.
Current data cites 5% vs 31% recurrence rate in hernias repaired at the initial
hospitalization vs. delayed repair. Recurrence rate in our patients is close to
zero. Anesthesia complications are cited to be as high as 5-12%. In our
patients, we have found no complications with regional anesthesia.
Conclusions: Inguinal hernia repair in premature infants is safe to perform under regional anesthesia. Potential complications can be minimized by operating before discharging the patients home.
Interosseous Nerve Palsy: Case Report And Review Of Radial Nerve Palsy
Sudhir Rao, MD, Orthopaedic Surgeon, Big Rapids Orthopaedic PC and Premier Hand Center, Big Rapids, MI
and posterior interosseous nerve palsy is the most frequently encountered nerve
palsy in the upper limb. Accidental
trauma is the leading cause but iatrogenic injury is not uncommon.
The case illustrates posterior interosseous nerve injury following an
Neuromuscular anatomy and surgical technique are highlighted to get a better
understanding of the challenge at hand.
Neuromuscular anatomy and surgical technique are highlighted to get a better
understanding of the challenge at hand.
Various clinical presentations are discussed. Treatment of radial nerve palsy is
Various clinical presentations are discussed. Treatment of radial nerve palsy is
This paper draws attention to a serious and sometimes preventable nerve injury. The audience will be able to suspect, diagnose and offer treatment guidelines on the basis of this presentation
Transplantation And Tolerance: Are We There Yet?
Reza Saidi, MD, FICS, Assistant Professor of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital
Department of Surgery, Division of Organ Transplantation, Providence, RI
Organ transplantation is not only considered as the last resort therapy but also as the treatment of choice for many patients with end-stage organ damage. Recipient-mediated acute or chronic immune response is the main challenge after transplant surgery. Nonspecific suppression of host immune system is currently the only method used to prevent organ rejection. Lifelong immunosuppression will cause significant side effects such as infections, malignancies, chronic kidney disease, hypertension and diabetes. This is more relevant in children who have a longer life expectancy so may receive longer period of immunosuppressive medications. Efforts to minimize or complete withdrawal of immunosuppression would improve the quality of life and long-term outcome of pediatric transplant recipients.
Non-Lung Primary Malignancies Presenting In The Lung Parenchyma
Tracy Sambo, MD, MS, FICS (Jr), Surgical Resident - Presence St. Joseph Hospital, Chicago, IL
Only a small minority of lung cancer patients present with parenchymal malignancies that are not either standard histology lung cancers (i.e., non-small cell/small cell) or metastatic lesions from primary cancers elsewhere in the body. Surgical practitioners need to be cognizant of these types of neoplasms to provide a thorough and expeditious evaluation of patients with these tumors. This presentation will illustrate the scenarios in which different types of non-standard primary lung tumors present, thus enabling the learner to recognize the possibility of non-traditional lung cancer during evaluation of a pulmonary mass or infiltrate. The intended audience will gain a better understanding of the pathophysiology of these disease processes which will translate into more cost effective delivery of care and improvements in patient survival.
Cloacae Sepsis With Multiple Brain Abscesses
Francis Gregory Samonte, MD, Assistant Professor, Neurophysiology, De Lasalle University, Philippines, San Diego, CA
is a clinically significant Gram-negative, anaerobic, rod-shaped bacterium. In
recent years, E. cloacae has emerged as one of the most commonly found
nosocomial pathogen in neonatal units, with several outbreaks of infection being
reported (J. Hosp. Infect.70,7-14 (2008). This microorganism may be transmitted
to neonates through contaminated intravenous fluids, total parenteral nutrition
solutions and medical equipment. However, there has been very few cases (if any)
reported of this infection complicating brain abscess in adults.
It is an important case not only because of the rarity of this infection in the setting of brain abscess, but also because the need to further understand and elucidate the possible relationship between this gut flora and the pathogenesis which may have influenced the brain abscesses formation.
Cholecystectomy in Portal Vein Thrombosis and Cavernous Transformation
Frank P. Schulze, MD, FICS, Surgeon-in-chief, St. Marien-Hospital, ICS European Federation Secretary, ICS Past-President of the German Section
Mülheim an der Ruhr, Germany
Laparoscopic cholecystectomy is the Gold-standard in the therapy of symptomatic
gallstones. However, in patients with portal vein thrombosis the perioperative
risk is significantly increased and a cavernous transformation is a special
challenge for the performing surgeon. Only few cases have been reported.
A 51 year old male patient suffered for more than 8 years from symptomatic
gallstones. 2 years prior to cholecystectomy he developed a biliary pancreatitis
with a long-term hospital stay following diabetes mellitus und chronic exocrine
pancreas dysfunction. A complete portal vein thrombosis with cavernous
transformation developed. The patient suffered from weekly colics. Preoperative
ultrasound and MRI showed a complete portal vein thrombosis with a cavernous
transformation of the hepatoduodenal ligament including Calot’s triangle. A
laparoscopic cholecystectomy was performed. The positions of the trocar sites
were chosen carefully under respect of the umbilical vein and visible
collaterals. Preparation was performed under highest respect to the cavernous
transformation and under generous use of vascular clips. The cavernous
transformation was preserved.
The total operating time was 87 minutes. Intraoperative blood-loss was minimal.
Postoperative Doppler ultrasound showed the collaterals of the cavernous
transformation open and with good flow. The postoperative laboratory findings
were identical to preoperative. The patient was dismissed at day 3 after
Conclusion: The indication for cholecystectomy in patients with known complete portal vein thrombosis and cavernous transformation should be restrictive due to the overall increased perioperative risks. However, if a patient suffers from frequent colics in short intervals laparoskopic cholecystektomy is an justifiable option. With respect to the special anatomy and an increased risk for bleeding the operation should be performed by an experienced HBP-surgeon.
Gastric Emptying: Pylorus-Preserving Versus Non-Pylorus-Preserving
Pancreaticoduodenectomy - Systemic Review And Meta-Analysis
Awinderpreet Singh, MD, Fellow Hepato-Biliary Program, Providence Hospital, Southfield-MI
A systemic literature search was performed using PubMed and EMBASE databases to
identify randomized controlled and retrospective series comparing PPPD
(pylorus-preserving pancreaticoduodenectomy) and NPPPD (non-pylorus preserving
was performed using Review Manager 5.0, and
heterogeneity was measured with I2 statistic. A fixed or random effects model
was used when there heterogeneity was observed. DGE was the primary outcome.
A total of 377 abstracts were evaluated and 24 articles (9 randomized controlled
trials-RCT, 11 retrospective studies and 2 prospective studies) were deemed
eligible for analysis. DGE was significantly increased in PPPD (357 out of 1874,
19.1%) compared to NPPPD (193/1101, 17.5%) with
an odds ratio of 1.81, 95% CI, 1.18-2.77, p=0.007) ( Figure 1). This
finding was also observed in the subset analysis of RCT (PPPD, 26.8% vs NPPPD,
Conclusion: These findings suggest that pylorus preservation is associated with an increased rate of DGE as compared to non-pylorus preserving pancreaticoduodenectomy.
Outcomes of the Bilaminar Repair Sandwich Technique" for" Closure of
Large, Complex Abdominal Wall Defects
Lauren Spoo, MD, OB-GYN Resident, Baylor College of Medicine, Houston, TX
Complex ventral hernias occur in up to 15% of patients undergoing abdominal
surgery. Management of these large ventral hernias remains challenging due to
complex operative conditions, intense post-operative pain, potential respiratory
compromise and lateral muscle traction predisposing to early recurrence. Despite
recent advances in technique and materials, the overall recurrence rate can be
unacceptably high, with reported recurrence rates varying between 15-21% for
open repair within 36 months.The author first introduced his variation of
Guarnieri’s “sandwich technique”¯
in 2011, which combines CST with both a biologic mesh underlay and overlay. The purpose of this study is to report long-term
outcomes of the author’s original newly-proposed bilaminar repair “Sandwich
technique”¯ with the aim to raise awareness of this technique
among various specialties.
Medical records were reviewed from patients who underwent ventral hernia repair
using two layers of biologic mesh with or without CST from 2005 to 2014.
The primary outcome that we will be reporting is hernia recurrence rate.
Secondary outcomes will include early and late complications and mortality.
There were approximately 150 patients who fit our criteria with a follow-up
period of up to nine years. We will analyze the data collected to report the
total number of patients who fit our search criteria, the median age, median
follow-up time, and patient demographics, including co-morbidities. We will
report on the type of hernias present, the type of surgery performed, including
whether or not additional procedures such as dermolipectomy were performed, the
type and rate of complications observed, and the recurrence rate to-date.
Conclusion: We hypothesize based on our clinical observations that the bilaminar repair “sandwich technique”¯ using dual-layer biologic mesh and CST is a superior technique with low recurrence rates for repair of large, complex, and recurrent ventral hernias.