Operative Management Of Patients Research Articles

Interval operative management in patients admitted with acute obstruction due to incarcerated paraesophageal hernia.

Acute incarcerated paraesophageal hernias (PEH) have historically been considered a surgical emergency. Emergent operations have a higher rate of morbidity and mortality compared to elective surgery. Our institution has adopted a strategy of initial conservative management in patients presenting with acute obstruction from an incarcerated PEH who are clinically stable. Patients are given at least 24h for their symptoms to improve (selective nasogastric decompression). If symptoms resolve, contrast on an upper GI study passes to the small bowel, and liquids are tolerated, patients are discharged with planned interval repair. We sought to characterize the outcomes of this interval surgical strategy for incarcerated PEH. A retrospective chart review was performed to identify patients admitted to a single institution between October 2019 and September 2023 with an incarcerated PEH. Patients taken directly to surgery within 24h were excluded. A total of 45 patients admitted with obstruction from an incarcerated PEH were identified. Ten patients (22%) were taken urgently to surgery due to clinical instability and were excluded. Of the remaining 35 patients, 23 (66%) resolved their obstruction with conservative non-operative management and were offered planned interval PEH repair (successful conservative management). In the successful conservative management cohort, there was one unplanned readmission before interval PEH repair. Average time between discharge and repair was 25days. Complication rates did not differ in those who failed and in those who had a successful conservative management result. The cumulative length of stay for those who succeeded in conservative management (including days for the interval surgery) was equivalent with those who underwent PEH repair during the index admission. A trial of conservative management in clinically stable patients with symptomatic incarcerated PEH appears to be safe and often avoids emergent repair without increasing perioperative complications or total days in the hospital.

Management and outcomes of splenic injuries secondary to blunt trauma in patients presenting to major trauma hospitals in Aotearoa New Zealand.

Non-operative management of splenic injuries has significantly increased in the last decade with an increased emphasis on splenic preservation. This shift was assisted by increased availability of angioembolization, however, potential geographical variability in access exists in Aotearoa New Zealand (AoNZ). The aim of this study was to assess the management of splenic injury across AoNZ. Five-year retrospective study of all patients admitted to AoNZ hospitals with blunt major trauma and a splenic injury. Patients were identified using the National Trauma Registry and cross-referenced with the National Minimum Data Set to determine their management. The primary outcome was the non-operative rate. Seven hundred seventy-three patients were included. Four hundred sixty-nine presented to a tertiary major trauma hospital and 304 to a secondary major trauma hospital. A difference was found in the rate of non-operative management between tertiary and secondary hospitals (P = 0.019). The rate of non-operative management was similar in mild (P = 0.814) and moderate (P = 0.825) injuries, however, significantly higher in severe injuries in tertiary hospitals (P = 0.009). No difference in mortality rate was found. This study found a difference in the management of splenic injuries between tertiary and secondary major trauma hospitals; predominantly due to a higher rate of operative management in patients with severe injuries at secondary hospitals. Despite this, no difference in mortality rate was found between tertiary and secondary hospitals.

Risk of Acute Compartment Syndrome in Pediatric Patients With Tibial Tubercle Avulsion Fractures: A Retrospective Review.

Tibial tubercle avulsion fractures (TTAFs) represent 0.4% to 2.7% of pediatric physeal injuries. These injuries are thought to confer a risk of acute compartment syndrome (ACS), and these patients are often admitted for compartment monitoring and, in many cases, undergo prophylactic fasciotomy. This study sought to review our institution's experience with TTAF and associated compartment syndrome in pediatric patients. All patients aged 8 to 18 years with TTAF at our institution from January 1, 2017 to January 1, 2023 were retrospectively reviewed. Patient demographics, injury mechanism, fracture morphology, and postinjury course were reviewed. ACS was diagnosed by clinical exam or necessitating therapeutic compartment fasciotomy. A total of 49 TTAFs in 47 patients were included in the final analysis. The mean age was 14.5 ± 1.2 years (range: 11 to 17), and males were significantly older than females (14.6 ± 1.1 vs 13.3 ± 1.3 y, P = 0.01). The average body mass index was 27.1 ± 7.0, and males had a significantly lower body mass index than females (26.3 ± 6.5 vs 34.1 ± 8.5, P = 0.03). Basketball was the most common mechanism of injury (49%), followed by soccer (13%), football (11%), trampoline (6%), fall (6%), jumping (4%), lacrosse (4%), running (4%), and softball (2%). The Ogden fracture types were as follows: I: 10%; II: 16%; III: 41%; IV: 24%; V: 8%. Thirty-four patients (69%) were admitted to the hospital for at least one night after presentation. Forty-six (96%) underwent surgical fixation an average of 3.5 days after injury. No patients developed ACS during their post-injury or postoperative course. Three patients underwent the removal of hardware. No other complications were observed. The average follow-up duration was 238 days. The results of this study suggest that the risk of ACS in pediatric patients with TTAF may be small enough to allow for same-day discharge after diagnosis or operative management in patients deemed to be sufficiently low risk by clinical judgment. Level III-retrospective comparative study.

An Age-Stratified Analysis of Early Postoperative Mortality Among Medicare-Eligible Patients With Common Gastrointestinal and Hepato-pancreato-biliary Malignancies.

Background: The frequency of major cancer surgery in the elderly (≥80years) has increased concomitantly with the rise in average age of the population. We assessed early postoperative mortality following hepato-pancreato-biliary (HPB) and gastrointestinal (GI) procedures for common malignancies stratified by age. Methods: The National Cancer Database (2004-2017) was queried for patients who underwent resection for GI (gastroesophageal and colorectal) or HPB (pancreatic adenocarcinoma, biliary tract, and primary liver) cancers. We compared early postoperative mortality (30d and 90d) stratified by age (65-79 vs ≥80years) and procedure, and compared survival outcomes by age and operative vs nonoperative management. Results: A total of 709,358 patients were included. The 30-day mortality ranged from 1.8% to 5.8% among patients 65-79years and from 3.2% to 12.4% among patients ≥80years depending on procedure. The 90-day mortality ranged from 3.6% to 10.6% in patients 65-79years compared to 8.4%-21.0% among patients ≥80years. The overall 90-day mortality was 5.2% for patients 65-79years and 12.0% for patients ≥80years (P < .001). Age ≥80 was associated with worse survival among operatively managed patients with each upper GI, HPB, and lower GI malignancy relative to younger patients on multivariable analysis. However, operative management of patients ≥80years was associated with improved survival relative to nonoperative management. Discussion: Elderly patients suffer higher postoperative mortality after major GI and HPB cancer surgery, but operative management is associated with improved survival among patients ≥80years as compared to nonoperative management. These data are important to contextualize when counseling elderly patients on their treatment options for localized GI and HPB cancers.

Poster 308: Clinical Outcomes After Multi-ligamentous Knee Injuries in Patients Over 40-Years-Old at Average 4-Years Follow-Up

Objectives: Multi-ligamentous knee injuries (MLKIs) are typically caused by high-energy mechanisms that warrant complex clinical decision-making and operative management to achieve optimal outcomes for patients. There is limited literature regarding these rare presentations, with even less information examining the clinical outcomes with respect to the age at which the injury was sustained. The purpose of this study is to investigate clinical outcomes following surgical treatment of MLKIs in patients who were at least 40-years-old at the time of their injury. Methods: The study design was a multi-center retrospective cohort study. Forty-four patients who underwent surgical repair for MLKI from May 2013 to August 2021 and were at least 40-years-old at the time of their injury were identified from two separate institutions. Patients-reported outcomes assessed included International Knee Documentation Committee Subjective Knee (IKDC) Subjective Knee Form, the Lysholm Knee Score, the Tegner Activity Scale (TAS), return-to-sport and return-to-work surveys, and Visual Analogue Scale (VAS) for pain and satisfaction. A multiple regression model was used to quantify the impact of various factors related to the initial injury, including age, sex, BMI, time of follow-up, history of dislocation with injury, and mechanism of injury on the assessed outcome measures. Results: The mean age of the cohort was 48.1 ± 7.0 years old. The mean overall follow-up was 60.8 months ± 36.3 (range 12-167)]. This cohort reported the following: mean IKDC of 63.4 ± 23.5, mean Lysholm score of 72.6 ± 23.6, and mean Tegner scores of 6.3 ± 2.2 before injury and 4.0 ± 2.0 at the time surveyed. These scores align similarly to the literature, indicating mediocre daily functional status. There were 18 patients that reported engagement in sports, with only 5 returning at a mean of 55.5 (± 26.2) weeks. The multiple linear regression model found dislocation to have a coefficient of -22.17 in relation to IKDC (p = 0.009), indicating that prior dislocation would predict a significant functional detriment as measured by the IKDC. A similar regression model with the Lysholm score as the outcome variable found dislocation to have a coefficient of -19.18 (p=.053), approaching significance. None of the other included variables were found to be significantly predicative of poorer outcome measures (p &gt; 0.05), including age. Conclusions: These results demonstrate that age may not be a significant factor to consider with respect to operative management in patients over 40 years old. Instead, dislocation status was found to be a much more significant predictor of clinical outcomes following operative management of MLKIs. Further research should be directed toward understanding which predisposing factors affect the long-term outcomes of MLKI injuries, given the often random nature of their presentation.

The Philadelphia Shriners Hospital Approach to Brachial Plexus Birth Injury.

The care of children with brachial plexus birth injuries (BPBI) is a complex multidisciplinary endeavor. At the Shriners Hospital for Children in Philadelphia, we have sought to elevate the quality of care delivered to patients through outcomes research and collaboration with colleagues around the world. Our approach to the management of this challenging pathology has evolved time and again. Here, we describe our current approach to patient assessment and operative management in patients with BPBI and its many sequelae.

A retrospective analysis of different treatments of posterior acetabular wall fracture

Introduction/Objective. The objective of the paper is an analysis of clinical outcomes of non-surgical conservative and operative management of patients with posterior acetabular wall fractures. Methods. We investigated 88 fractures of the acetabular joint, 31 of which were treated surgically and 57 non-surgically. Only screws or reconstruction plates and screws were used for surgical treatment and traction in patients who underwent nonsurgical treatment. The study period lasted at least three years. The measures used to assess the outcome of operative, surgical and non-operative, conservative approach were Merle d?Aubigne modified score, Harris hip score, and Matta?s radiometric criteria. Results. Matta?s evaluation criteria showed an excellent score of 40.4% in conservatively treated patients; 19.4% in patients who underwent surgery; a good score of 49.1% in conservatively treated patients; and 48.4% in patients who underwent surgery. Comparation between two patient groups differently treated, by Merle d?Aubigne tool, showed excellent results for 56.1% conservatively treated patients and 25.8% in those patients who underwent surgery, and good results in 29.8% conservatively treated patients and 38.7% in patients who underwent surgery. Harris hip score (excellent results were showed in 54.4% for non-operative-treated patients) also showed statistical significance, p &lt; 0.005. Conclusion. Proper diagnostics and a proper definitive diagnosis can help avoid surgical treatment if the fracture cannot be treated surgically, making the postoperative period more comfortable for the patient.

Management of pancreatic trauma in urban India: A multicenter study

BackgroundPancreatic trauma occurs in 0.2–2% of patients with blunt trauma and 1–12% of patients with penetrating trauma. The mortality and morbidity rates range from 9 to 34% and 30–60% respectively. We aimed to review the management of pancreatic trauma in a multicenter database from India. MethodsWe analyzed all patients who suffered a pancreatic injury and who were included in the multicenter prospective observational study ‘Towards Improved Trauma Care Outcomes (TITCO)’. ResultsOf the 16047 trauma cases, 1134 (7.1%) patients suffered abdominal trauma. Of all those with abdominal trauma, 55 patients (4.9%) had injury to the pancreas. 28 patients (50.9%) with pancreatic trauma were managed conservatively. 27 patients (49.1%) underwent surgical exploration in the form of laparotomies. 11 procedures were undertaken for pancreas. A total of 45 (82%) patients had associated injuries along with pancreatic injury. Thorax (19) (including injuries to lung, pleura and ribs), liver (17), bowel (14) and spleen (13) were the most common associated injuries. ConclusionConservative management was as common as operative management in patients with pancreatic injuries. Most (80%) grade III/IV underwent operative treatment. Many patients (82%) had associated injuries. Level of evidenceIII.

Hybrid laparoscopic pancreaticoduodenectomy: Ukrainian single center experience

Background: Minimally invasive pancreaticoduodenectomy both laparoscopic and robotic is becoming a new standart of operative management in patients with distal bile duct carcinoma, periampullary adenocarcinoma, pancreas head cancer, and duodenal cancer worldwide. It shows lot of advantages for patients but the same time stays quite challenging for surgeons performing it. However, there are significant limitations to the successful implementation of minimally invasive pancreaticoduodenectomies in developing countries, including Ukraine.

Laparoscopic Ultrasound for Bile Duct Imaging during Cholecystectomy: Clinical Impact in 785 Consecutive Cases.

The influence of laparoscopic ultrasonography (LUS) on the operative management of patients during laparoscopic cholecystectomy (LC) has not been examined in a large unselected series. Seven hundred eight-five consecutive LC operations were reviewed to determine whether the findings of LUS for bile duct imaging altered operative management. Patients were analyzed according to the primary indication for imaging: anatomic identification (group I), possible common bile duct stones (group II), and routine use absent other indications (group III). LUS demonstrated the cystic duct-common bile duct junction, the common hepatic duct, the common bile duct to the ampulla, and the right hepatic artery in 95.8% of cases. Among 56 of 111 (50%) patients in group I for whom initial dissection failed to result in adequate anatomic identification, subsequent LUS provided sufficient anatomic identification to allow completion of a laparoscopic operation in 87.5%. Group I patients were more likely to have acute cholecystitis (p < 0.0001) and Tokyo Guidelines 2018 grade II or III acute cholecystitis (p < 0.001). LUS changed operative management for 19 of 256 (7.5%) group II patients and 10 of 361 (2.8%) group III patients by demonstrating common bile duct stones that resulted in common bile duct exploration with stone clearance. Five patients had common bile duct stones that were not detected by LUS. There were no major bile duct or vascular injuries. The primary value of LUS during LC is for anatomic identification when there are severe local inflammatory conditions. In this setting, LUS imaging can facilitate safe completion of LC or an early decision for an alternate operative strategy. When performed primarily for common bile duct stones or as routine practice, LUS results in CBDE for a limited proportion of patients.

Racial Disparities in Surgery for Malignant Bowel Obstruction.

Operative management of patients with malignant bowel obstruction (MBO) may provide effective palliation, but is associated with substantial risks. This study aimed to analyze racial and ethnic differences in surgical outcomes for patients with MBO. This retrospective study, using National Surgical Quality Improvement Program (NSQIP) registry data from 2010 to 2019, compared differences in outcomes by race and ethnicity for 2762 patients undergoing surgery for MBO. Multivariable logistic regression controlled for relevant covariates. Black patients (n = 407) had higher rates of preoperative comorbidity and were more likely than White patients (n = 2081) to have major complications (28.5% vs 21.8%; p = 0.0031), overall complications (47.4% vs 40.4%; p = 0.0087), a longer median hospital stay (12 days; interquartile range [IQR, 8-19 days] vs 10 days [IQR, 7-17 days]; p = 0.0007), and unplanned readmission (17.1% vs 12.9%; p = 0.0266). Black patients had a similarmortality rateto that of White patients and were less frequently discharged to home (67.6% vs 73.0%; p = 0.0315). Differences in morbidity between Black patients and White patients persisted after controlling for potentially confounding variables. Hispanic patients had lower mortality than White patients (6.3% vs 13.1%; p = 0.0130) and a longer hospital stay (12 days [IQR, 8-18 days] vs 10 days [IQR, 7-17 days]; p = 0.0313). Outcomes did not differ between Asian patients and White patients. This study demonstrated significant disparities for Black patients undergoing surgery for MBO. Understanding and addressing what drives these differences, including systemic inequalities such as access to care and racial biases, is essential to theachievement of more equitable, higher-quality patient care.

A STUDY ON PATTERN OF BLUNT ABDOMINAL TRAUMA AND ITS OUTCOME FOLLOWING NON OPERATIVE MANAGEMENT

INTRODUCTION: Abdomen is the third most commonly injured part of the body following injuries to extremities and head. Blunt injury remains to be the most prevailing mode of abdominal injury. Motor vehicle accidents are the most common mode to cause Blunt abdominal trauma. Evolving imaging modalities like FAST, CT scans have resulted in signicant shift from surgical to more selective conservative management of blunt injury abdomen. MATERIALS AND METHODS: This is a prospective study of selected cases of Blunt injury abdomen managed in the Department of General Surgery in Rajah Muthiah Medical College and Hospital (RMMCH) during the period from September 2019 to October 2021. AIMS AND OBJECTIVES: The current study establishes the incidence and demographic distribution of patients who have sustained blunt abdominal trauma, also gives an outline which type of patient will benet conservative management and detects downfalls of surgical and conservative management and identies the causes of failure of Non operative management following blunt injury abdomen. RESULTS: In our study males were more commonly affected than females in the ratio 4:1 and age group involved ranging from 4 years to 69 years, majority were in second, third, fourth decades taking a toll of 71.25% of patients. The common presentations in these victims were abdominal pain, tenderness, diffuse guarding, rigidity, abdominal distention, sluggish/ absent bowel sounds, pallor, hypotension with features of shock. In unstable patients to detect hemoperitoneum, ultrasonography/FAST was a very helpful mode of investigation. But, it missed 3 cases with kidney injury, 5 cases with liver injury, and 9 cases with splenic injury. It is not an imaging of choice to detect bowel, kidney, pancreas and mesenteric injuries. CECT abdomen is the investigation of choice to grade the organ injuries. 37 patients with splenic injuries were identied by CT abdomen, of which 29 were managed conservatively. CT abdomen detected liver injuries in 21 patients, of which 16 were managed conservatively. Kidney injures were picked up in 5 patients with help of CT abdomen and all were subjected to conservative management. MANAGEMENT: From a total of 100 patients studied, 64 patients were selected for conservative management after initial resuscitation. Most common organ to get involved following Blunt abdominal trauma is Spleen (37%), followed by liver (21%), mesentery, small bowel and bladder. Out of 37 patients with splenic injuires, 29 were managed conservatively. 16 cases with isolated hepatic injury, 5 cases with kidney injury, 2 cases with bladder injury, 2 patients with mesenteric injury and one patient with pancreatic injury were managed conservatively. Morbidity and mortality: Mortality was not observed in patients subjected to conservative management. A total of 4 cases died in the operative group. Two patients due to pancreatic head transection, one due to associated head injury, one due to delayed hospitalization. The duration of hospitalization in patients who were managed conservatively ranged from 9-11 days and 14-20 days in patients who underwent surgery. One patient developed pseudocyst of pancreas following pancreatic injury and another patient developed clot retention following conservative management for bladder injury. The causes of failure of non operative management in patients with blunt abdominal trauma were patients with pancreatic head transection, ongoing hemorrhage/ features of peritonitis with hemoperitoneum and hollow viscus perforation. CONCLUSION: The success rates following conservative management of solid organ injures after blunt injury abdomen have been increasing and it is quite challenging also, since it requires close observation by experienced surgeon and there is a narrow line to choose the line of management (conservative / surgical) for better outcome. Involvement of multiple intra abdominal organs, other associated extra abdominal injuries, coexisting comorbid diseases and late presentation following injury increases the morbidity and mortality. Ultimately early diagnosis, aggressive adequate resuscitation and timely surgical intervention when needed in severely injured patients may boost the outcome in these patients who have failed conservative management.

EP.FRI.614 An Atypical Case of Small Bowel Obstruction in the Virgin Abdomen: Case Presentation and Literature Review

Abstract Aims The management of post-operative adhesional small bowel obstruction (SBO) has shifted from the historical motto of “the sun should never rise and set on a complete SBO” to a non operative approach in selected patients. Despite this shift, the operative management of patients with SBO with a virgin abdomen is still encouraged. Methods We present an atypical case of SBO managed conservatively with resolution, without surgical intervention. A literature review is conducted and our case compared with the current literature. A treatment algorithm is presented. Results A 57 year old with a virgin abdomen presented with vomiting and abdominal pain. Computed tomography was consistent with mid to distal SBO proximal to the terminal ileum, in the context of a high riding caecum. He was managed conservatively. Symptoms resolved within 12 hours without gastrograffin. Gastrograffin was subsequently given to ensure contrast was present in the large bowel. At 6 month follow up he remains symptom free. Discussion Many advocate surgery is the cornerstone of the management of SBO in the virgin abdomen. There is little evidence to support this. Recent emerging evidence challenges this view. Ultimately the clinical evaluation of the patient is paramount in selecting which patients can be managed conservatively. A longer interval to operation may carry greater risk of ischaemia and bowel resection. Therefore careful patient selection and serial examination is vital and one should have a low threshold for early operative intervention in the patient which isn't settling. Follow up should be tailored to each patient.

Operative management in patients with upper tract urothelial carcinoma in Iceland: a population-based study

Objective Radical nephroureterectomy is the standard treatment of organ-confined upper tract urothelial carcinoma (UTUC). The objective of this study was to investigate survival and bladder recurrence rate in Icelandic patients with UTUC who underwent radical nephroureterctomy (RNU) or other procedures with curative intent. Material and methods All patients who were diagnosed with UTUC in Iceland from 2003 to 2016 and treated with curative intent were included in the study. Information on patients was obtained retrospectively from patients’ medical records and from the Icelandic Cause of Death Registry. Results Overall 63 patients underwent a procedure for UTUC with curative intent in Iceland during the study period. The median age was 71 years and the majority were male (65%). In 50 patients (79%), the tumor was a primary UTUC. The most common procedure was RNU (78%) and eight patients (13%) underwent a kidney-sparing procedure. No patient died within 90 d of surgery. Twenty-eight patients (44%) had pathological stage T2 or higher, whereas 35 patients (56%) had pathological stage T1 or lower. The median follow-up time was 98.8 months . During the follow-up time 25 patients (40%) were diagnosed with recurrence in the bladder. Five-year cancer-specific survival (CSS) was 67%. Conclusions This population-based study shows that the oncologic outcome in Icelandic patients with UTUC is similar to what has been reported in other countries. Bladder recurrence rate is high and can hopefully be reduced by improvements in surgical and intravesical instillation treatment. Possibly more kidney-sparing surgeries could have been done during the study period; however, careful selection for those procedures is mandatory.

Association of perioperative ibuprofen exposure with post-tonsillectomy bleeding requiring operative management

IntroductionPediatric tonsillectomy is one of the most common surgical procedures performed in the United States. The safety of ibuprofen use after surgery is debated given concern for increased bleeding. The primary objective of this study was to compare the rate of post-tonsillectomy hemorrhage requiring operative management in patients who received ibuprofen perioperatively vs. patients who did not. MethodsRetrospective cohort study of patients 0–18 years old who underwent tonsillectomy with or without adenoidectomy (T&A) with recorded inpatient medication administration data at a single tertiary care institution from 1/2005-1/2019. The association between perioperative medication administration and return to operating room (OR) for control was evaluated using multivariable logistic regression adjusted for patient demographics and operative indication. Secondary outcomes evaluated included the time to operative bleed when it occurred. ResultsA total of 4098 patients with a median age of 6 years old (IQR 4–10) underwent T&A over the study period. The overall rate of post-tonsillectomy hemorrhage requiring OR was 3.37% (n = 138/4098). After adjustment for confounders, the odds of bleeding requiring OR did not differ significantly between the ibuprofen (OR 1.16, 95% CI (0.76, 1.74), 3.55%, n = 41/1,156, p = 0.47) and non-ibuprofen groups (3.30%, n = 97/2942). The median time to bleeding requiring OR was postoperative day 6.5 (IQR6-8) in the ibuprofen group and day 6 (IQR 3–8) in the non-ibuprofen group. ConclusionsNo difference in post-tonsillectomy hemorrhage requiring OR was observed between patients receiving perioperative ibuprofen versus those patients not receiving this medication. Additional research is required to definitively determine a safe dose and interval for ibuprofen administration following tonsillectomy.

Obesity and risk for open reduction and internal fixation of syndesmotic injuries in the setting of concomitant ankle fractures

IntroductionThe association between obesity and the need for open reduction and surgical fixation of the syndesmosis in the setting of malleolar ankle fractures remains to be elucidated. Therefore, the primary objective of this study was to assess the relationship between obesity, ankle fracture complexity, and the need for open reduction and fixation of the syndesmosis. MethodsA retrospective analysis of the NSQIP database was performed for patients undergoing surgical fixation of isolated, closed ankle fractures. Patients were grouped by fracture pattern into 6 cohorts (uni-, bi- and trimalleolar ankle fractures with or without syndesmotic injury). Demographic data was collected and compared between groups and logistic regression analyses were used to assess the relationship between body mass index (BMI) and ankle fracture pattern. ResultsA total of 15,841 patients (mean age 48.9 years) were identified for inclusion. Regression analyses revealed that BMI had a significant association with the incidence of open reduction and internal fixation of the ankle syndesmosis, but there was no association between BMI and malleolar fracture pattern. ConclusionsThis study demonstrates that elevated BMI is associated with an increased risk for open reduction and internal fixation of the syndesmosis in malleolar ankle fractures. However, obesity was not associated with ankle fracture pattern itself, whereas older age, female sex, and white race were more significant predictors of fracture complexity. This data provides a framework for further evaluation of the effect that both modifiable and non-modifiable risk factors have on fracture complexity and operative management of patients with such injuries. Level of evidenceCase-control study. Level III.

High-Resolution Maxillofacial Computed Tomography Is Superior to Head Computed Tomography in Determining the Operative Management of Facial Fractures

BackgroundComputed tomography of the head (CTH) and maxillofacial bones (CTMF) can be performed concurrently, but CTMF is frequently ordered separately, after facial fractures identified on CTH scans. This study aims to evaluate whether obtaining additional CTMF after CTH changes operative management of patients with facial trauma. Materials and methodsA retrospective chart review was performed of all patients with facial trauma who presented to our level 1 trauma center between January 2009 and May 2019. CTH and CTMF were reviewed for each patient. Fracture numbers and patterns were compared to determine if CTMF provided additional information that necessitated change in management, based on predetermined criteria. ResultsA total of 1215 patients were assessed for facial trauma. Of them, 899 patients underwent both CTH and CTMF scans. CTH identified 22.7% less fractures than CTMF (P < 0.001); specifically, more orbital, nasal, naso-orbito-ethmoid, zygoma, midface, and mandible fractures (P < 0.001). Of all patients 9.2% (n = 83) of patients with nonoperative fractures on CTH were reclassified as operative on CTMF; 0.6% (n = 5) with operative patterns on CTH were reclassified as nonoperative on CTMF, and 18.1% (n = 163) experienced a changed in their operative plan though operative fractures were seen on both imaging modalities. Additional findings seen on CTMF delegated change in the operative plan in 27.9% (n = 251) of cases. ConclusionsCTMF scans are necessary to determine operative intervention. As CTH and CTMF are constructed from the data, physicians should consider ordering both scans simultaneously for all patients with facial trauma to limit radiation exposure, control costs, and avoid delays in care.

Early operative management in patients with adhesive small bowel obstruction: population-based cost analysis.

BackgroundAdhesive small bowel obstruction (aSBO) is a potentially recurrent disease. Although non‐operative management is often successful, it is associated with greater risk of recurrence than operative intervention, and may have greater downstream morbidity and costs. This study aimed to compare the current standard of care, trial of non‐operative management (TNOM), and early operative management (EOM) for aSBO.MethodsPatients admitted to hospital between 2005 and 2014 in Ontario, Canada, with their first episode of aSBO were identified and propensity‐matched on their likelihood to receive EOM for a cost–utility analysis using population‐based administrative data. Patients were followed for 5 years to determine survival, recurrences, adverse events and inpatient costs to the healthcare system. Utility scores were attributed to aSBO‐related events. Cost–utility was presented as the incremental cost‐effectiveness ratio (ICER), expressed as Canadian dollars per quality‐adjusted life‐year (QALY).ResultsSome 25 150 patients were admitted for aSBO and 3174 (12·6 per cent) were managed by EOM. Patients managed by TNOM were more likely to experience recurrence of aSBO (20·9 per cent versus 13·2 per cent for EOM; P < 0·001). The lower recurrence rate associated with EOM contributed to an overall net effectiveness in terms of QALYs. The mean accumulated costs for patients managed with EOM exceeded those of TNOM ($17 951 versus $11 594 (€12 288 versus €7936) respectively; P < 0·001), but the ICER for EOM versus TNOM was $29 881 (€20 454) per QALY, suggesting cost‐effectiveness.ConclusionThis retrospective study, based on administrative data, documented that EOM may be a cost‐effective approach for patients with aSBO in terms of QALYs. Future guidelines on the management of aSBO may also consider the long‐term outcomes and costs.

TIMING OF SURGICAL INTERVENTION AFTER VENTRICULAR SEPTAL RUPTURE

Ventricular septal rupture (VSR) is a rare but lethal complication of acute myocardial infarction (AMI). patients presenting with ST-elevation MI (STEMI) were evaluated for heart rupture (VSR ) based on reperfusion strategy. , After undergoing a primary percutaneous coronary intervention (PCI), VSR was reported to occur in 0.23-0.71% of patients. Post-infarction VSR carries significant mortality (36.%) despite aggressive surgical management. Rupture develops after full-thickness (transmural) infarction of the ventricular septum and can occur at any anatomic location. Ventricular septal rupture is likely to be associated with total occlusion of the infarct-related artery. the newly formed communication results in left to right shunting of oxygenated blood from the high-pressure left ventricle to the lower-pressure right ventricle. .Mortality was highest in patients who underwent operation in the first 24 h, consistent with other investigators. The case reflects the important problem after myocardial infarction , ventricular septal rupture and challenges the timing of intervention Patient 70 year old,male,caucasion was admitted in our hospital with encephalopathy and hypotension.ECG revealed ST segment elevation in II,III,AVF,V4-V6 lead,ST segment depression in AVL,V1-V3 lead. Koronarography detected left main artery without important stenosis, 95 % stenosis of middle segment and 75% stenosis of distal part of left anterior descending artery.40% stenosis of middle segment of right coronary artery, occlusion of posterior descending artery.After recanalization and balloon predilatation of posterior descending artery, was parformed drug eluted stant implantation. transthoracic echocardiography (TTE) detected of postinfarction VSR (pict 3). The Colour Doppler was demonstrated of flow across the septum and left to rigt shunt. Conclusion: Ventricular septal rupture (VSR) is a rare but lethal complication of acute myocardial infarction (AMI). Mortality of patients is significantly depending o n timing of surgery. Operative management of patients can be complex, and having a systematic approach is helpful. The cornerstone of medical management of VSR is afterload reduction, and may be considered routine care.. According our case , surgical intervention was delayed and dispite adequate treatment patient was died . There is no clear evidence to guide the surgical management of patients who are in shock, as all approaches have shown extremely high mortality. Possible strategies include emergent surgery on individuals with marked haemodynamic instability and circulatory compromise.

Splenic trauma in the twenty-first century: changing trends in management.

Over the past three decades, management of blunt splenic trauma has changed radically. Use of improved diagnostic techniques and proper understanding of disease pathology has led to nonoperative management being chosen as the standard of care in patients who are haemodynamically stable. This review was undertaken to assess available literature regarding changing trends of management of blunt splenic trauma, and to identify the existing lacunae in nonoperative management. The PubMed database was searched for studies published between January 1987 and August 2017, using the keywords 'blunt splenic trauma' and 'nonoperative management'. One hundred and fifty-three articles were reviewed, of which 82 free full texts and free abstracts were used in the current review. There is clear evidence in published literature of the greater success of nonoperative over operative management in patients who are haemodynamically stable and the increasing utility of adjunctive therapies like angiography with embolisation. However, the review revealed a lack of universal guidelines for patient selection criteria and diagnostic and grading procedures needed for nonoperative management. Indications for splenic artery embolisation, the current role of splenectomy and spleen-preserving surgeries, together with the place of minimal access surgery in blunt splenic trauma remain grey areas. Moreover, parameters affecting the outcomes of nonoperative management and its failure and management need to be defined. This shows a need for future studies focused on these shortcomings with the ultimate aim being the formulation and implementation of universally accepted guidelines for safe and efficient management of blunt splenic trauma.