Search

Introduction Solitary pulmonary nodules (SPNs) are common, but the clinical relevance of these nodules is unknown. Utilizing current screening guidelines, we sought to better characterize the national incidence of clinically important SPNs within the largest universal health care system in the nation. Materials and Methods TRICARE data were queried to identify SPNs for ages 18–64 years. SPNs that had been diagnosed within a year with no prior oncologic history were included to ensure true incidence. A proprietary algorithm was applied to determine clinically significant nodules. Further analysis characterized incidence by age grouping, gender, region, military branch, and beneficiary status. Results A total of 229,552 SPNs were identified with a 60% reduction seen after application of the clinical significance algorithm (N = 88,628). The incidence increased in each decade of life (all P Conclusions This analysis represents the largest evaluation of SPNs to date combined with clinical relevance adjustment. These data suggest a higher incidence of clinically significant SPNs starting at an age of 44 years in nonmilitary or retired women localized to the Midwest and Western regions of the United States.

Robotic surgery has provided an attractive minimally invasive option for esophagectomy. Benefits include magnified 3D visualization, a variety of instruments with 7 degrees of motion that simplify sewing and fine dissection, as well as autonomous control of the operation with the use of 3 robotic arms. We provide a detailed review of how we perform robotic esophagectomies that conclude in the chest. A video demonstrating the crucial steps is provided. Although 3-field robotic assisted minimally invasive esophagectomy (RAMIE) is possible when needed, we will focus here on approaches with anastomosis in the chest.

BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA), a minimally invasive alternative to resuscitative thoracotomy, has been associated with significant ischemia reperfusion injury (IRI). Resuscitation strategies using adenosine, lidocaine, and magnesium (ALM) have been shown to mitigate similar inflammatory responses in hemorrhagic and septic shock models. This study examined the effects of ALM on REBOA-associated IRI using a porcine model. METHODS Animals underwent a 20% controlled hemorrhage followed by 30 minutes of supraceliac balloon occlusion. They were assigned to one of four groups: control (n = 5), 4-hour ALM infusion starting at occlusion, 2-hour (n = 5) and 4-hour (n = 5) interventional ALM infusions starting at reperfusion. Adenosine, lidocaine, and magnesium cohorts received a posthemorrhage ALM bolus followed by their respective ALM infusion. Primary outcomes for the study assessed physiologic and hemodynamic parameters. RESULTS Adenosine, lidocaine, and magnesium infusion after reperfusion cohorts demonstrated a significant improvement in lactate, base deficit, and pH in the first hour following systemic reperfusion. At study endpoint, continuous ALM infusion initiated after reperfusion over 4 hours resulted in an overall improved lactate clearance when compared with the 2-hour and control cohorts. No differences in hemodynamic parameters were noted between ALM cohorts and controls. CONCLUSION Adenosine, lidocaine, and magnesium may prove beneficial in mitigating the inflammatory response seen from REBOA-associated IRI as evidenced by physiologic improvements early during resuscitation. Despite this, further refinement should be sought to optimize treatment strategies.

Mobile smartphone thermal imaging (MTI) devices correlate with blood flow, which makes them appealing adjuncts during reconstructive surgery. MTI was assessed in the setting of deep inferior epigastric artery perforator (DIEAP) free flaps. We hypothesized that MTI can be a surrogate for blood flow to identify microvascular flow insufficiencies.Nineteen patients underwent 30 DIEAP flaps for breast reconstruction. Images were obtained preoperatively, intraoperatively, and at instances of concern for flap viability. Three groups were evaluated: normal DIEAP flaps (NDFs), flaps with arterial insufficiency (AI), and flaps with venous congestion (VC).All flaps were successful. There were significant temperature increases from max ischemia (24.5 ± 2.1°C) to 1 min after anastomosis (27.2 ± 1.6°C, P 0.001). NDFs continued to warm until the final MTI was taken when leaving the operating room. There were no differences between MTI flap temperatures before transfer to the chest and after completion of microanastomosis. With questionable flap viability, VC and AI temperatures were found to be significantly colder than the NDF group (28.3 ± 1.9°C versus 32.2 ± 1.8°C, P = 0.003) in the VC group and (27.2 ± 0.7°C versus 32.2 ± 1.8°C, P = 0.001) in the AI group. After correction of the identified flow insufficiency, VC and AI rewarmed and temperatures were no different compared with NDF.MTI recognizes microanastomotic failure and is a practical adjunct in the evaluation of free flap perfusion.

Background Currently, no evidence compares outcomes for techniques utilizing surgical specimen extractions bags versus unprotected extraction. Methods Evaluation of sleeve gastrectomies performed at two high-volume centers. Cases where an extraction bag was used (+EB) were compared to bag-less extraction (-EB). Outcomes included operative contamination, surgical site infections and extraction-site hernias. Results 674 patients were evaluated (417 in the +EB group and 257 in the -EB group). Preoperative characteristics were similar between groups. There was a trend toward shorter operative times with the -EB group (-EB = 100 min vs + EB = 106 min, p = 0.07). Gross spillage was documented as a contaminated case in 0.4% of -EB cases compared to 1.2% in +EB cases (p = 0.51). Two superficial infections were appreciated (1.2% = +EB vs 0.7% = -EB, p = 0.7) with one post-operative abscess in the -EB group (p = 0.61). One post-operative hernia was seen in each group (p = 0.62). Discussion Bag-less extraction is a safe, resource conscious method that may potentially decreased operative time.

BACKGROUND: Persistent air leaks after thoracic trauma are associated with significant morbidity. To evaluate a novel pectin sealant in a swine model of traumatic air leaks, we compared a pectin biopolymer to standard surgical and fibrin-based interventions. METHODS: A standardized lung injury was created in male Yorkshire swine. Interventions were randomized to stapled wedge resection (N=5), topical fibrin glue (N=5), fibrin patch (N=5) and a pectin sealant (N=6, Figure). Baseline, pre- and post-intervention tidal volumes (TV) were recorded. Early success was defined as the return to near-normal TV (≥ 95% of baseline). Late success was defined as no detectable air leak in the chest tube after chest closure. RESULTS: There were no differences in injury severity between groups (mean TV loss = 62ml±17, p =0.2). Early success was appreciated in 100% (N=6) of the pectin interventions which was significantly better than the fibrin sealant (20%, N=1), fibrin patch (20%, N=1) and stapled groups (80%, N=4, p=0.01). The percent of return to baseline TV after sealant intervention was significantly increased in the pectin (98%) and staple arms (97%) compared to the fibrin sealant (91%) and fibrin patch arms (90%) (p = 0.02; p = 0.03). Late success was also improved with the pectin sealant: no air leak was detected in 83% of the pectin group compared to 40% in the stapled group (p=0.008)—90% of the fibrin-based interventions resulted in continuous air leaks (p=0.001). CONCLUSION: Pectin-based bioadhesives effectively seal traumatic air leaks upon application in a porcine model. Further testing is warranted as they may provide a superior parenchymal-sparing treatment option for traumatic air leaks. LEVEL OF EVIDENCE: Not applicable as an animal study STUDY TYPE: Orginal Article

This article briefly reviews the literature supporting the practice of extended pulmonary resection followed by a comprehensive description of the indications, workup, and technique commonly used for patients requiring extended pulmonary resections for advance lung cancers. The article also provides up-to-date advances in the field that have aided in the safe and effective practice of extended pulmonary resections.

Introduction Adhesion formation represents a major cause of long-term morbidity. Suspension of intra-abdominal contents in fluid medium may effectively prevent adhesion formation. We compare saline hydro-flotation (NS) to hyaluronate bioresorbable membranes (HBM) for adhesion prevention following surgery. Methods Animals were randomized to four groups: sham (no injury, n = 5), control (injury without intervention, n = 5), HBM (n = 20) or 10 cc NS (n = 21). Interventions were administered after standardized surgical trauma to the cecum and abdominal wall. Necropsies at two weeks were completed to compare adhesion burden using a customary scoring algorithm. Results Significant adhesion burden was noted in all rats. HBM sustained a more significant adhesion burden with higher total adhesion scores (HBM = 10 vs NS = 8.1/15, p = 0.02). Gross adhesion scores were lower with NS (5.6/9) compared to HBM (7.1/9, p = 0.01). Neo-vascularity was more common in HBM at 2.6/3 versus 1.9/3 with NS (p = 0.01). Percent of the cecum encased with adhesion was higher with HBM (42%) compared to NS (31%, p = 0.05). Discussion Fluid based anti-adhesion methods should be considered for abdominal adhesion formation prevention.

BACKGROUND High-grade solid organ injury is a major cause of mortality in trauma. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) can be effective but is limited by ischemia-reperfusion injury. Intermittent balloon inflation/deflation has been proposed as an alternative, but the safety and efficacy prior to operative hemorrhage control is unknown. METHODS Twenty male swine underwent standardized high-grade liver injury, then randomization to controls (N = 5), 60-min continuous REBOA (cR, n = 5), and either a time-based (10-minute inflation/3-minute deflation, iRT = 5) or pressure-based (mean arterial pressure

Background Bariatric surgery in advanced age patients (>65-years-old) has been proven safe and effective. Revisional bariatric surgery is infrequently required for cases of refractory obesity. However, there is a paucity of data regarding revisional surgery for the elderly. We hypothesize that revisional bariatric surgery is viable and safe in elderly patients. Methods Retrospective chart review of all bariatric revisions performed at two high-volume bariatric centers of excellence between 2011 and 2018. Perioperative and long-term outcomes were compared between patients >65 and those Results 145 bariatric revisions were performed for weight loss. 10% (N = 15) were >65 years old. There were no differences in mortality between the two groups There was a longer median length of stay in the younger cohort (2 vs 1 day, p = 0.001). Percent excess weight loss was similar at 12-months, as was resolution of comorbidities. Conclusions Bariatric revisions in elderly patients appears to be safe and effective. Revisional surgery in this population was not shown to have increased morbidity or mortality with similar excess body weight loss when compared to a younger cohort.

Objectives Partial restoration of aortic flow during resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated by some to mitigate distal ischemia. Our laboratory has validated the mechanics and optimal partial REBOA (pREBOA) flow rates using a prototype device. We hypothesize that pREBOA will increase survival when compared with full REBOA (fREBOA) in prolonged nonoperative management of hemorrhagic shock. Methods Twenty swine underwent placement of aortic flow probes, zone 1 REBOA placement, and 20% blood volume hemorrhage. They were randomized to either solid organ or abdominal vascular injury. The pREBOA arm (10 swine) underwent full inflation for 10 minutes and then deflation to a flow rate of 0.5 L/min for 2 hours. The fREBOA arm (10 swine) underwent full inflation for 60 minutes, followed by deflation/resuscitation. The primary outcome is survival, and secondary outcomes are serologic/pathologic signs of ischemia-reperfusion injury and quantity of hemorrhage. Results Two of 10 swine survived in the fREBOA group (2/5 solid organ injury; 0/5 abdominal vascular injury), whereas 7 of 10 swine survived in the pREBOA group (3/5 solid organ injury, 4/5 abdominal vascular injury). Survival was increased (p = 0.03) and hemorrhage was higher in the pREBOA group (solid organ injury, 1.36 ± 0.25 kg vs. 0.70 ± 0.33 kg, p = 0.007; 0.86 ± 0.22 kg vs. 0.71 ± 0.28 kg, not significant). Serum evidence of ischemia was greater with fREBOA, but this was not significant (e.g., lactate, 16.91 ± 3.87 mg/dL vs. 12.96 ± 2.48 mg/dL at 120 minutes, not significant). Swine treated with pREBOA that survived demonstrated trends toward lower alanine aminotransferase, lower potassium, and higher calcium. The potassium was significantly lower in survivors at 60 minutes and 90 minutes time points (5.97 ± 0.60 vs. 7.53 ± 0.90, p = 0.011; 6.67 ± 0.66 vs. 8.15 ± 0.78, p = 0.029). Calcium was significantly higher at 30 minutes, 60 minutes, and 90 minutes (8.56 ± 0.66 vs. 7.50 ± 0.40, p = 0.034; 8.63 ± 0.62 vs. 7.15 ± 0.49, p = 0.019; 8.96 ± 0.64 vs. 7.00, p = 0.028). Conclusion Prolonged pREBOA at a moderate distal flow rate provided adequate hemorrhage control, improved survival, and had evidence of decreased ischemic injury versus fREBOA. Prophylactic aggressive calcium supplementation may have utility before and during the reperfusion phase.

BACKGROUND During military combat operations and civilian night-time aeromedical transport, medical providers are frequently required to perform lifesaving interventions (LSIs) in low-light environments. Because definitive surgical care is often delayed until a white light environment is permissible, we sought to determine if night optical device (NOD) technology could enable surgical capabilities in blackout conditions. METHODS Using a crossover design, six surgeons performed 11 different procedures on six swine, three in normal light conditions (LC) and 3 in blackout conditions (BC) using two-chamber NODs after familiarization with the procedures in both conditions on manikins. Successful completion and procedural times were compared between groups. RESULTS Blackout conditions were confirmed with ambient light reading of 0.2 lux during BC versus 3962.9 lux for LC (p < 0.001). There were no significant differences in success rates for any procedure. There were no differences in operative times between BC and LC for extremity tourniquet placement, femoral artery cut-down and clamping, resuscitative thoracotomy, or percutaneous resuscitative endovascular balloon occlusion of the aorta placement. The following procedures took significantly longer in BC vs. LC: Focused Assessment with Sonography for Trauma examination (98 seconds vs. 62 seconds), peripheral IV placement (140 seconds vs. 35 seconds), intraosseous access (51 seconds vs. 26 seconds), jugular vein cut-down and access (237 seconds vs. 104 seconds), laparotomy and packing (71 seconds vs. 51 seconds), stapled splenectomy (137 seconds vs. 74 seconds), resuscitative endovascular balloon occlusion of the aorta placement via cutdown (1,008 seconds vs. 338 seconds), and cricothyroidotomy (177 seconds vs. 109 seconds) (all p < 0.05). CONCLUSION Lifesaving interventions can be safely and effectively performed in blackout conditions using NODs, although increased difficulty with select procedure types was identified. Focused training and technological improvements to currently available devices are needed. LEVEL OF EVIDENCE Basic science.

Background Stenosis is the most frequent airway complication after lung transplantation. When complete obstruction is diagnosed without possibility of recanalization, options are generally limited to either resection or retransplantation, both associated with increased morbidity and mortality. We describe our experience with a novel technique using electromagnetic navigational bronchoscopy (ENB) to recanalize the occluded airway after lung transplantation. Methods Patients who underwent lung transplantation between 2010 and 2016 with subsequent development of complete airway obstruction and failed conventional recanalization attempts were included in this study. All patients underwent attempted recanalization using ENB. Primary outcomes included success of the technique and long-term patency. Secondary outcomes included procedure-related complications. Results Four patients met inclusion criteria and underwent attempted recanalization using the ENB platform. Location of the obstruction was the bronchus intermedius in two patients, the lingular bronchus in one patient, and the left basilar bronchus in one patient. Mean length of stenosis was 8.8 mm. Three patients (75%) were successfully recanalized and all airways remain patent at 1, 48, and 66 mo. There were no procedure-related complications. The one patient who was unable to be recanalized successfully underwent bilobectomy and died 7 mo later. Conclusions ENB is a feasible method of airway recanalization in select patients with bronchial occlusion after lung transplantation. ENB recanalization spares lung parenchyma and avoids risks associated with surgical resection and retransplantation. This novel technique can be added to the armamentarium for thoracic surgeons who diagnose and treat this complicated problem.

Polycystic ovarian syndrome (PCOS) is a common endocrine disorder associated with obesity and infertility. Gastric bypass has been shown to be effective in treating these symptoms. However, the efficacy of vertical sleeve gastrectomy (VSG) has not been studied in the PCOS population. This study analyzed weight loss and fertility outcomes of VSG in this population. A retrospective review of patients with PCOS and without PCOS (CON) undergoing VSG from 2008 to 2016 was performed at two bariatric centers. BMI and percent excess weight loss (%EWL) were collected at 3, 6, and 12 months postoperatively. Patient characteristics and postoperative pregnancy status were compared between the two cohorts. One hundred nineteen PCOS patients were compared to 119 CON patients. Similar attrition rates were seen between cohorts at 3-month (5 vs 8%), 6-month (13 vs. 14%), and 12-month (18 vs. 13%) evaluation. PCOS patients had greater ΔBMI at 3 months (− 7.64 vs. − 6.82; p = 0.05), 6 months (− 10.56 vs. − 9.49; p = 0.02), and 12 months (− 12.43 vs. − 11.49; p = 0.04). PCOS patients also had greater %EWL at 12 months compared to CON (66 vs 60%; p = 0.05). Twenty-two percent of PCOS patients became pregnant within 12 months, 69% of which were previously nulliparous. Compared to non-PCOS patients, PCOS patients had greater postoperative ΔBMI and %EWL at 1 year. The majority of patients becoming pregnant after VSG were previously nulliparous. This study shows that VSG is effective for weight loss in PCOS patients with obesity and may positively augment effect fertility rates.

Traumatic coagulopathy has now been well characterized and carries high rates of mortality owing to bleeding. A 'factor-based' resuscitation strategy using procoagulant drugs and factor concentrates in lieu of plasma is being used by some, but with little evidentiary support. We sought to evaluate and compare resuscitation strategies using combinations of tranexamic acid (TXA), prothrombin complex concentrate (PCC), and fresh frozen plasma (FFP).Sixty adult swine underwent 35% blood volume hemorrhage combined with a truncal ischemia-reperfusion injury to produce uniform shock and coagulopathy. Animals were randomized to control (n = 12), a single-agent group (TXA, n = 10; PCC, n = 8; or FFP, n = 6) or combination groups (TXA-FFP, n = 10; PCC-FFP, n = 8; TXA-PCC, n = 6). Resuscitation was continued to 6 hours. Key outcomes included hemodynamics, laboratory values, and rotational thromboelastometry. Results were compared between all groups, with additional comparisons between FFP and non-FFP groups.All 60 animals survived to 6 hours. Shock was seen in all animals, with hypotension (mean arterial pressure, 44 mm Hg), tachycardia (heart rate, 145), acidosis (pH 7.18; lactate, 11), anemia (hematocrit, 17), and coagulopathy (fibrinogen, 107). There were clear differences between groups for mean pH (p = 0.02), international normalized ratio (p0.01), clotting time (CT; p0.01), lactate (p = 0.01), creatinine (p0.01), and fibrinogen (p = 0.02). Fresh frozen plasma groups had significantly improved resuscitation and clotting parameters (Figures), with lower lactate at 6.5 versus 8.4 (p = 0.04), and increased fibrinogen at 126 versus 95 (p0.01). Rotational thromboelastometry also demonstrated shortened CT at 60 seconds in the FFP group vs 65 seconds in the non-FFP group (p = 0.04).When used to correct traumatic coagulopathy, combinations of FFP with TXA or PCC were superior in improving acidosis, coagulopathy, and CT than when these agents are given alone or in combination without plasma. Further validation of pure factor-based strategies is needed.

Objective assessment of final resuscitative endovascular balloon occlusion of the aorta (REBOA) position and adequate distal aortic occlusion is critical in patients with hemorrhagic shock, especially as feasibility is being increasingly investigated in the prehospital setting. We propose that mobile forward-looking infrared (FLIR) thermal imaging is a fast, reliable, and noninvasive method to assess REBOA position and efficacy in scenarios applicable to battlefield and prehospital care.Ten swine were randomized to a 40% hemorrhage group (H, n = 5) or nonhemorrhage group (NH, n = 5). Three experiments were completed after Zone I placement of a REBOA catheter. Resuscitative endovascular balloon occlusion of the aorta was deployed for 30 minutes in all animals followed by randomized continued deployment versus sham in both light and blackout conditions. Forward-looking infrared images and hemodynamic data were obtained. Images were presented to 62 blinded observers for assessment of REBOA inflation status.There was no difference in hemodynamic or laboratory values at baseline. The H group was significantly more hypotensive (mean arterial pressure 44 vs. 60 mm Hg, p0.01), vasodilated (systemic vascular resistance 634 vs. 938dyn·s/cm, p = 0.02), and anemic (hematocrit 12 vs. 23.2%, p0.01). Hemorrhage group animals remained more hypotensive, anemic, and acidotic throughout all three experiments. There was a significant difference in the temperature change (ΔTemp) measured by FLIR between animals with REBOA inflated versus not inflated (5.7°C vs. 0.7°C, p0.01). The H and NH animals exhibited equal magnitudes of ΔTemp in both inflated and deflated states. Blinded observer analysis of FLIR images correctly identified adequate REBOA inflation and aortic occlusion 95.4% at 5 minutes and 98.8% at 10 minutes (positive predictive value at 5 minutes = 99% and positive predictive value at 10 minutes = 100%).Mobile thermal imaging is an easy, rapid, and reliable method for assessing distal perfusion after occlusion by REBOA. Smartphone-based FLIR technology allows for confirmation of adequate REBOA placement at the point of care, and performance was not degraded in the setting of major hemorrhage or blackout conditions.

Tension pneumothorax (tPTX) remains a major cause of preventable death in trauma. Needle decompression (ND) has up to a 60% failure rate.Post-mortem swine used. Interventions were randomized to 14G-needle decompression (ND, n = 25), bladed trocar with 36Fr cannula (BTW, n = 16), bladed trocar alone (BTWO, n = 16) and surgical thoracostomy (ST = 11). Simulated tPTX was created to a pressure(p) of 20 mmHg.Success (p 5 mmHg by 120 s) was seen in 41 of 68 (60%) interventions. BTW and BTWO were consistently more successful than ND with success rates of 88% versus 48% in ND (p .001). In successful deployments, ND was slower to reach p 5 mmHg, average of 82s versus 26s and 28s for BTW and BTWO respectively (p .001). Time to implement procedure was faster for ND with an average of 3.6s versus 16.9s and 15.3s in the BTW and BTWO (p .001). Final pressure was significantly less in BTW and BTWO at 1.7 mmHg versus 7 mmHg in ND animals (p .001).Bladed trocars can safely and effectively tPTX with a significantly higher success rates than needle decompression.

This article reviews the key steps required for preparation and execution of patient care during mass casualty (MASCAL) events. The experience provided by the recent conflicts in the Middle East as well as multiple civilian attacks or incidents resulting in mass number of casualties have afforded the health care providers with a wealth of data and experience to aid in the preparation and execution when forced to deal with this type of situation. The following compiles the lessons learned by presenting the reader with ten critical concepts that are crucial to proper preparation and deployment of resources to effectively manage and successfully approach a mass casualty event.

This article reviews the finer points of thoracic trauma seen during combat and provides parallels to the civilian sector for potential implementation. Lessons learned during recent conflicts in Iraq (Operation Iraqi Freedom), Afghanistan (Operation Enduring Freedom) as well as the ongoing military actions targeting the Islamic State (ISIS) have equipped combat surgeons with a breadth of knowledge concerning the management of complex thoracic trauma. The unique environment provided by war inherently fosters the development of innovation. Management of combat injuries has become more crucial to all trauma surgeons, as high-velocity weaponry and global terrorism can produce similar injury patterns in the civilian trauma setting. This review focuses on unique injuries seen in austere war-time environments with focus on thoracic trauma. Applications to civilian trauma are highlighted throughout the article with the hope that the experience gained by combat surgeons may aide in the advancement of trauma care.

BACKGROUND Over the past decade, there has been a resurgence of tourniquet use in civilian and military settings. Several key challenges include assessment of limb perfusion and adequacy of tourniquet placement, particularly in the austere or prehospital environments. We investigated the utility of thermal imaging to assess adequacy of tourniquet placement. METHODS The FLIR ONE smartphone-based thermal imager was utilized. Ten swine underwent tourniquet placement with no associated hemorrhage (n = 5) or with 40% hemorrhage (n = 5). Experiment 1 simulated proper tourniquet application, experiment 2 had one of two tourniquets inadequately tightened, and experiment 3 had one of two tourniquets inadequately tightened while simulating blackout-combat conditions. Static images were taken at multiple time points up to 30 minutes. Thermal images were then presented to blinded evaluators who assessed adequacy of tourniquet placement. RESULTS The mean core temperature was 38.3 °C in non-hemorrhaged animals versus 38.2 °C in hemorrhaged animals. Hemorrhaged animals were more hypotensive (p = 0.001), anemic (p < 0.001), vasodilated (p = 0.008), and had a lower cardiac output (p = 0.007) compared to non-hemorrhaged animals. The thermal imaging temperature reading decreased significantly after proper tourniquet placement in all animals, with no difference between hemorrhaged and non-hemorrhaged groups at 30 minutes (p = 0.23). Qualitative thermal image analysis showed clearly visible perfusion differences in all animals between baseline, adequate tourniquet, and inadequate tourniquet in both hemorrhaged and non-hemorrhaged groups. Ninety-eight percent of blinded evaluators (n = 62) correctly identified adequate and inadequate tourniquet placement at 5 minutes. Images in blackout conditions showed no adverse impact on thermal measurements or in the ability to accurately characterize perfusion and tourniquet adequacy. CONCLUSIONS A simple handheld smartphone-based forward looking infrared radiometry device demonstrated a high degree of accuracy, reliability, and ease of use for assessing limb perfusion. Forward looking infrared radiometry also allowed for rapid and reliable identification of adequate tourniquet placement that was not affected by major hemorrhage or blackout conditions.

Background Bariatric surgery makes up an increasing percentage of general surgery training. The safety of resident involvement in these complex cases has been questioned. We evaluated patient outcomes in resident performed laparoscopic bariatric procedures. Methods Retrospective review of patients undergoing a laparoscopic bariatric procedure over seven years at a tertiary care single center. Procedures were primarily performed by a general surgery resident and proctored by an attending surgeon. Primary outcomes included operative volume, operative time and leak rate with perioperative outcomes evaluated as secondary outcomes. Results A total of 1649 bariatric procedures were evaluated. Operations included laparoscopic bypass (690) and laparoscopic sleeve gastrectomy (959). Average operating time was 136 min. Eighteen leaks (0.67%) were identified. Graduating residents performed an average of 89 laparoscopic bariatric cases during their training. There were no significant differences between resident levels with concern to operative time or leak rate (p 0.97 and p = 0.54). Conclusions General surgery residents can safely perform laparoscopic bariatric surgery. When proctored by a staff surgeon, a resident's level of training does not significantly impact leak rate.

In 2012 the FDA approved a magnetic sphincter augmentation (MSA) device (LINX, Torax Medical, Inc) for placement around the lower esophageal sphincter as an alternative approach to fundoplication for gastroesophageal reflux disease (GERD). This is a relatively new procedure and there is not widespread familiarization with the standard indications and techniques of device placement. We present two operative videos to highlight the standard surgical technique and technical points needed for successful LINX placement. First will be placement in a standard indications setting of uncomplicated GERD with no hiatal hernia. Second will be placement with complicated anatomy due to alterations from prior gastric surgery and a hiatal hernia. Our experience has revealed that the LINX device can be placed safely in patients with normal or significantly altered anatomy but requires adherence to several key principles and technical points. This procedure offers a new option that is anatomically and physiologically unique compared to standard fundoplication, and that offers highly effective control of GERD with a less invasive approach.

Introduction Umbilical reconstruction in pediatric patients who have developed a large proboscoid redundancy can be challenging after standard umbilical repair. We present a simple and unique surgical technique that results in a cosmetically appealing reconstruction. Operative technique The operation is initiated with circumferential redundant skin excision and isolation of the hernia sac. Primary fascial repair is performed. Reconstruction utilizes the cut dermal/epidermal edge by approximating it to the exposed fascia just below the skin edge outside of the fascial repair in a purse string fashion for the creation of a neoumbilicus. Conclusion This simple technique is unique from any currently published methods and results in a cosmetically pleasing reconstruction without evidence of any incision. Level of evidence Level V: Expert Opinion.

BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a significant advancement in the control of noncompressible truncal hemorrhage. However, its ischemic burden and reperfusion injury following balloon deflation limits its utilization. Partial restoration of aortic flow during REBOA has the potential to balance hemorrhage control and ischemia. This study validates the mechanics, physiology, and optimal partial flow rates using a prototype partial REBOA (pREBOA) device. METHODS Twenty-five swine underwent placement of aortic flow probes and zone 1 pREBOA. Experiment 1 (N = 5) animals were not injured and assessed the tested the catheters ability to titrate and control flow. Experiment 2 (N = 10) added 20% hemorrhage and either solid organ, or abdominal vascular injury to compare flow rate and rebleeding from injuries. Experiment 3 (N = 10) swine were similarly prepared, hemorrhaged, and underwent pREBOA at set partial flow rates for 2 hours followed by complete deflation for 30 minutes. RESULTS Balloon volume at minimum flow (mean, 0.09 L/min) was 3.5 mL to 6.0 mL. Half maximal flow was achieved with 56.5% of maximum balloon inflation. Partial REBOA allowed very fine titration of flow rates. Rebleeding occurred at 0.45 L/min to 0.83 L/min. Distal flow of 0.7 L/min had 50% survival, 0.5 had 100% survival, and 0.3 L had 50% survival with mean end lactates of 9.6, 12.6, and 13.3, respectively. There was a trend toward hyperkalemia and hypocalcemia in nonsurvivors. CONCLUSION The pREBOA device demonstrated a high level of titratability for restoration of aortic flow. An optimal partial flow of 0.5 L/min was effective at hemorrhage control while limiting the burden of ischemic injury, and extending the tolerable duration of zone 1 occlusion. Aggressive calcium supplementation prior to and during partial occlusion and reperfusion may be warranted to prevent hyperkalemic arrest.

Introduction Magnetic resonance imaging (MRI) is commonly utilized in treatment planning of breast cancer patients. While axillary lymph node findings are routinely reported in these studies, the utility of these findings remains unclear. Methods In this retrospective study from 2008–2014, women diagnosed with invasive breast cancer who did not undergo neoadjuvant therapy were reviewed. MRI characteristics of axillary findings were compared to the final pathologic results. Results 210 of 338 female patients met inclusion criteria and comprised our patient cohort. MRI was found to have a sensitivity and specificity of 45% and 84%, respectively. The negative predictive value was 78% with an accuracy of 72% and a false negative rate of 14%. MRI was more often accurate in younger patients (p Conclusion MRI of the axilla is not a reliable tool for axillary staging in women with breast cancer. Microabstract The significance of magnetic resonance imaging (MRI) findings of the axilla after routine preoperative imaging is poorly understood. We evaluated the perioperative course including axillary findings on MRI and compared them to the final axillary pathology of 210 women with invasive breast cancer. MRI did not show adequate predictive capability in determining women with invasive cancer progression to the axilla. Clinical practice points Preoperative magnetic resonance imaging of the breast is often obtained for women diagnosed with breast cancer. Findings in the axilla are often commented on in the radiology reports of these studies. There is limited data evaluating the significance of axillary finding in breast cancer imaging. The current literature differs in two important ways from the findings revealed in this study. First, the majority of the current literature focuses on imaging obtained using axillary specific protocols. These findings to not contribute transferable information for the typical clinical practice as these protocols are not commonly ordered or performed. Second, currently available studies have small cohorts, typically less than one hundred patients, or are systematic reviews. This study provides analysis of 210 patients over 6 years and represents the largest single study cohort that evaluates the clinical significance of axillary findings obtained during preoperative MRI of the breast. The findings reported here will aid clinicians when completing the preoperative work up for women diagnosed with breast cancer. Further, the subgroup analysis of our true positives presents an opportunity to potentially identify a new set of breast cancer patients that would have a greater benefit from neoadjuvant chemotherapy and thus spare them the morbidity of axillary lymph node dissection.

Background Staple line leak after sleeve gastrectomy (SG) is a rare but dreaded complication with a reported incidence of 0% to 8%. Many surgeons routinely test the staple line with an intraoperative leak test (IOLT), but there is little evidence to validate this practice. In fact, there is a theoretical concern that the leak test may weaken the staple line and increase the risk of a postop leak. Methods Retrospective review of all SGs performed over a 7-year period was conducted. Cases were grouped by whether an IOLT was performed, and compared for the incidence of postop staple line leaks. The ability of the IOLT for identifying a staple line defect and for predicting a postoperative leak was analyzed. Results Five hundred forty-two SGs were performed between 2007 and 2014. Thirteen patients (2.4%) developed a postop staple line leak. The majority of patients (n = 494, 91%) received an IOLT, including all 13 patients (100%) who developed a subsequent clinical leak. There were no (0%) positive IOLTs and no additional interventions were performed based on the IOLT. The IOLT sensitivity and positive predictive value were both 0%. There was a trend, although not significant, to increase leak rates when a routine IOLT was performed vs no routine IOLT (2.6% vs 0%, P = .6). Conclusions The performance of routine IOLT after SG provided no actionable information, and was negative in all patients who developed a postoperative leak. The routine use of an IOLT did not reduce the incidence of postop leak, and in fact was associated with a higher leak rate after SG.

Background Current major national guidelines recommend early mammographic evaluation after completion of breast conservation therapy (BCT). However, the clinical utility of these recommendations are not well defined. Our objective was to determine the role of post-treatment mammogram after BCT. Methods A retrospective review at a single tertiary referral institution of all female patients (>18 years old) who underwent BCT for invasive breast cancer and ductal carcinoma in situ was performed. Results Between 2004 and 2013, 342 patients met inclusion criteria. All patients underwent post-BCT mammograms with a mean time of 198 ± 59 days after treatment. Nineteen patients (5%) had findings that prompted biopsy on initial post-treatment mammogram. Of those 19 patients, there was 1 (5%) patient that had malignancy identified on biopsy. This represents .3% of overall patients who underwent mammography in the early postoperative period. Conclusions The utility of early mammogram after BCT is limited and prompts unnecessary diagnostic procedures, which are marginally beneficial. We recommend resetting the timing of mammography to resume 12 months after BCT is complete.

Background Tranexamic acid (TXA) has been shown to decrease mortality and blood product requirements in severely injured patients. Tranexamic acid has also been hypothesized to prevent secondary brain injury in patients with traumatic brain injury. While prior studies have demonstrated improved neurologic outcomes associated with TXA administration in severely injured pediatric patients, no such studies have been performed in adults. Methods A retrospective review of all adult trauma admissions to North Atlantic Treaty Organization hospitals in Iraq and Afghanistan between 2008 and 2015. Univariate and multivariate analysis was used to identify factors associated with TXA administration. Patients without a documented head Abbreviated Injury Scale (AIS) were excluded. Patients were propensity matched based on demographics, mechanism of injury, Injury Severity Score (AIS/ISS), presenting Glasgow Coma Scale (GCS) score, initial vitals/laboratory values, and initial transfusion requirement. Primary outcomes were in-hospital mortality and neurologic outcomes measured by discharge GCS scores. Secondary outcomes were respiratory failure and rates of thromboembolic events. Results Four thousand four hundred seventy-six injured patients 18 years or older were evaluated. Two hundred sixty-five (5.9%) of these patients required a massive transfusion in the first 24 hours, and 174 (3.9%) received TXA. The TXA patients had significantly higher ISS, more penetrating injuries, lower presenting GCS, higher incidence of severe head injury (AIS > 3), and higher transfusion requirements. Ninety-two patients were included in the propensity matched cohort. Of these, patients who received TXA had significantly lower mortality rate (0% vs. 10.1%, p = 0.02) and improvement of GCS score to 14 to 15, irrespective of admission GCS compared with patients who did not receive TXA (100% vs. 87%, p = 0.01). There were no significant differences in number of thromboembolic events recorded between the two groups. Conclusion The TXA administration in adult combat trauma patients was independently associated with decreased mortality and improved neurologic outcomes, with no increase in thromboembolic events. Further study of the possible mechanisms and effect of TXA on brain injury and neurologic outcomes is warranted. Level of evidence Therapeutic, level IV.

Solitary rectal ulcer is a relatively rare disorder that is generally poorly understood. Because its presentation is often associated with anorectal pain and bleeding, and the disorder may mimic the presentation of rectal cancer or inflammatory bowel disease, it is important to have a solid basis for recognition and treatment of this disorder.

Noncompressible hemorrhage can be controlled using resuscitative endovascular balloon occlusion of the aorta (REBOA). Prolonged ischemia limits REBOA application during Zone 1 deployment. Intermittent inflation/deflation may effectively mitigate this problem.A lethal abdominal vascular injury was created in 28 swines. Animals were randomized to controls (n = 7), 60 minutes full REBOA (FR, n = 5), time-based intermittent REBOA (iRT, n = 7), and pressure-based REBOA (iRP, n = 9). Intermittent groups had an initial inflation for 15 minutes, followed by 10-minute inflation: 3-minute deflation cycles (iRT), or an inflate/deflate schedule based on mean arterial pressure (MAP) less than 40 mm Hg (iRP). Experiments were concluded after 120 minutes or death (MAP20 mm Hg).Intermittent REBOA animals all survived to 120 minutes versus 15 minutes for controls and 63 minutes for FR (p0.001). After 60 minutes, FR animals were more hypotensive (MAP 20 mm Hg vs. 80 mm Hg [iRP] and 100 mm Hg [iRT]; p0.001), had lower cardiac output (1.06 mL/min vs. 5.1 L/min [iRP] and 8.2 L/min [iRT]; p0.001), higher lactate (12.5 mg/dL vs. 8.5 mg/dL [iRP], p = 0.02), and decreased clot firmness on rotational thromboelastometry than iRP/T (64 mm vs. 69 mm [iRP] and 69 mm [iRT], p = 0.04). Acidosis was worse in iRT versus iRP at 120 minutes (pH 7.28 vs. pH 7.12; p = 0.02), improved lactate (11.9 mg/dL vs. 16.3 mg/dL; p = 0.04), and decreased whole blood resuscitation (452 mL vs. 646 mL, p = 0.05). Blood loss (clot weight) was higher in controls (2.0 kg) versus iRT and iRP (1.16 kg and 1.23 kg; p0.01) and not different from FR (0.87 kg; p = 0.10).Intermittent REBOA can maintain supraceliac hemorrhage control while decreasing distal ischemia in a swine model. Prolonged survival times, decreased acidosis, and lower resuscitation requirements indicate that this technique could potentially extend Zone 1 REBOA deployment times. Schedules based on MAP may be superior to time-based regimens.

The early use of tranexamic acid (TXA) is strongly advocated in patients who are likely to require massive transfusion to decrease mortality. This study determines the influence of hemorrhage on the pharmacokinetics of TXA in a porcine model.The investigation was a prospective experimental study in Yucatan minipigs. First, in vitro plasma-cell partitioning of TXA was evaluated by inoculating whole blood with known aliquots, centrifuging, and measuring the supernatant with high-performance liquid chromatography with mass spectrometry (HPLC-MS). Then, using in vivo modeling, normovolemic and hypovolemic (35% reduction in blood volume) swine (n = 4 per group) received 1 g of intravenous TXA and had blood sampled at 14 time points over 4 hours to determine baseline clearance via HPLC-MS. Additional swine (n = 4) were hemorrhaged 35% of their blood volume, and TXA was administered as a 15 mg/kg infusion over 10 minutes followed by infusion of 1.875 mg/kg per hour to simulate massive hemorrhage scenario. During the first hour of TXA administration, one total blood volume was hemorrhaged and simultaneously replaced with TXA free blood. Serial blood samples and the hemorrhaged blood were analyzed by HPLC-MS to determine the percentage of dose lost via hemorrhage.Clearance of TXA was diminished in the hypovolemic group compared with the normovolemic group (115 ± 4 vs 70 ± 7 mL/min). Percentage of dose lost via hemorrhage averaged 25%. The lowest measured plasma level during the exchange transfusion was 34 μg/mL.Mean 25% of the present 2017 Joint Trauma System Clinical Practice Guideline dosing of TXA can be lost to hemorrhage if a blood volume is transfused within an hour of initiating therapy. In the case of TXA, which has limited distribution and is administered during active hemorrhage and massive blood transfusions, replacement strategies should be developed and tested to find simple methods of adjusting the current dosing guidelines to maintain therapeutic plasma concentrations.Therapeutic, level II.

Complications from adhesions after intra-abdominal surgery accounts for ~6% of hospital admissions. Currently, hyaluronate/carboxymethylcellulose represents the main option to prevent postoperative adhesion formation. Human amniotic membrane contains inherent anti-inflammatory properties that mitigate adhesion formation.This study aimed to evaluate adhesion generation after surgical trauma with amniotic membranes compared with standard intraperitoneal adhesion barriers.This study is a double-blinded, prospective evaluation.This study was conducted at an animal research facility.Forty male rats were studied.Laparotomy was performed with peritoneal disruption to the cecum. Animals were randomly assigned to 1 of 5 groups: sham, control, saline, hyaluronic acid membrane, or amniotic membrane. Animals were euthanized at 14 days.Independent gross and histological assessments of adhesions were analyzed between groups by using adhesion scoring and microscopy. Scoring was based on the percentage of the cecum involved (0-4), vascularity of adhesions (0-3), strength (0-3), inflammation (0-3), and fibrosis (0-3). Adhered tissue was harvested for polymerase chain reaction analysis for gene regulation activity.All rats survived 14 days. Adhesions were observed in all animals. There were significantly fewer adhesions in the amniotic membrane group (2) versus hyaluronic acid (3) group (p = 0.01). The percentage of adhesion to the cecum was lower in the amniotic membrane group (29%) than in the hyaluronic acid group (47%, p = 0.04). Histological examination showed no significant difference between or within the 3 groups for inflammation or fibrosis. Genetic analysis of adhered tissues supported high rates of epithelialization and inhibition of fibrosis in the amniotic membrane group.We are limited by the small sample size and the preclinical nature of the study.Human-derived amniotic membrane is effective at reducing intraperitoneal adhesion after surgical trauma and is superior to the current antiadhesion barriers. Amniotic membranes are well absorbed and demonstrate short-term safety. See Video Abstract at http://links.lww.com/DCR/A554.

Patients undergoing pulmonary resection all exhibit, to some degree, a level of pulmonary dysfunction. This is due to the physiologic stress of the procedure performed, the patient’s comorbidities, and preexisting cardiopulmonary reserve. Although prognostic factors for intensive care requirement exist, to date, there is no consensus for postoperative admission. Institutional practices vary across the country, with patients often admitted to intensive care for surveillance. Guidelines published from the American Thoracic Society in 1999 emphasize that admission to the ICU be reserved for those patients requiring care and monitoring for severe physiologic instability. Admissions following pulmonary resection are typically due to respiratory complications and are an independent predictor of mortality. The following chapter will review the indications for admission to the ICU and common issues encountered following pulmonary resection and conclude with a discussion of the management of patients undergoing pulmonary transplantation.

Bariatric surgery results in massive weight loss, leaving many patients with redundant skin that can cause significant physical and psychosocial limitations. We sought to identify variables associated with postoperative complications and adjuncts associated with the mitigation of postoperative complications.A retrospective review was performed of all post-bariatric surgery patients who underwent panniculectomy over a 10-year period.Total 706 patients included. Overall complication rate was 56%: dehiscence (24%), surgical site infection (22%), seroma (18%), and post-operative bleeding (5%). Return to operating room rate was 12%. Significant factors were: BMI26 (p 0.01), fleur-de-lis panniculectomy (p 0.01), concomitant hernia repair (p 0.01). Multivariate regression analysis demonstrated ASA class2 (OR 1.97, p 0.05) and incision type (OR 1.64, p 0.05) to be independent predictors of morbidity.High morbidity for post-bariatric panniculectomy is primarily local wound complications. Potentially modifiable factors that increase the complication risk profile include higher BMI, higher ASA class, and the use of fleur-de-lis incision.

Background Traumatic Rib Cage Hernias (TRCH) requiring operative repair are rare and there is currently no literature to guiding surgical management. Methods Perioperative review of TRCH over 32 years. Five operative grades were developed based on extent of tissue/bone damage, size, and location. Results Twenty-four patients (20 blunt, 4 penetrating) underwent operative repair. Lung was the herniated organ in 88% with a median of 4 rib fractures and average size of 60.25 cm. Types of operation were well clustered by assigned TRCH grade. The majority required mesh (75%) and/or rib plating (79%). Complex tissue flap reconstruction was required in 10%. Full range-of-motion was maintained in 88% with79% returning to pre-injury activity levels. Five patients had continued pain at final follow up (mean = 7months). Conclusion The size and degree of injury has important implications in the optimal surgical management of TRCHs. These operative grades effectively direct surgical care for these rare and complex injuries.