450 N Roxbury Dr Suite 224
Beverly Hills CA 90210
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Role of imaging in the diagnosis of occult hernias. - JAMA surgery
Occult hernias are symptomatic but not palpable on physical examination. This is more commonly seen with inguinal hernias. Early diagnosis and treatment of occult hernias are essential in relieving symptoms and improving patients' quality of life.To determine the effectiveness of imaging-ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI)--in the diagnosis of occult inguinal hernia.A retrospective medical records review of surgical patients with groin and pelvic pain, 2008-2013, was conducted in a single-surgeon hernia specialty practice. Thirty-six patients met the following inclusion criteria: (1) examination findings suggestive of but not necessarily diagnostic for inguinal hernia; (2) imaging of the groin and/or pelvis with US, CT, and MRI; and (3) an operation to address the groin or pelvic pain. Fifty-nine groins were included.Sensitivity, specificity, and predictive values of US, CT, and MRI for detection of occult inguinal hernia.The number, sensitivity, specificity, positive predictive value, and negative predictive value of each modality were, respectively: US (9, 0.33, 0, 1.00, and 0), CT (39, 0.54, 0.25, 0.86, and 0.06), and MRI (34, 0.91, 0.92, 0.95, and 0.85). Among multiply imaged groins in which CT examination missed a diagnosis of hernia, MRI correctly detected an occult hernia in 10 of 11 cases (91%).Ultrasonography and CT cannot reliably exclude occult groin abnormalities. Patients with clinical suspicion of inguinal hernia should undergo MRI as the definitive radiologic examination.
When it is not a Spigelian hernia: abdominal cutaneous nerve entrapment syndrome. - The American surgeon
Abdominal wall pain at the linea semilunaris is classically the result of a Spigelian hernia. If no hernia is detected, these patients may be left with chronic pain without a diagnosis or treatment. A retrospective review was performed of patients presenting with abdominal wall pain at the linea semilunaris between 2009 and 2012. Of the 14 patients, three (21%) were diagnosed with a Spigelian hernia confirmed by imaging. The remaining patients were eventually diagnosed with abdominal cutaneous nerve entrapment syndrome (ACNES). The average delay in diagnosis was 4 years with patients with ACNES suffering twice as long with chronic pain. Patients with a Spigelian hernia and ACNES had different demographics and presenting complaints. Physical examination findings were nondiagnostic. Of the patients with ACNES, five (50%) had resolution of pain with serial nerve blocks alone; another five proceeded to surgical neurectomy with resolution of their pain. Thus, to prevent delay in diagnosis and treatment, patients with chronic abdominal wall pain at the linea semilunaris should first be ruled out for Spigelian hernia. Then, they should be evaluated and treated for ACNES.
Outreach in surgery at the undergraduate level: an opportunity to improve surgical interest among women? - The American surgeon
Medical career choice is often formed at the premedical level, thus surgeons must reach out to undergraduates to enhance interest in surgery. Because there is a predominance of women among undergraduates (57%), this outreach also serves as an opportunity to introduce women to a surgical career. We developed an undergraduate course ("Surgery 99") offering course credit for participation in clinical research projects in surgery, shadowing surgeons in the operating room, and receiving mentorship for a surgical career. Six surgeons (50% women) served as course instructors. The final exam was a thesis with oral presentation. For enrollment, 132 students applied and 13 were accepted each quarter. Eleven students (85%) were women. None of the students had prior exposure to surgery. All but one student (93%) found the experience met or exceeded their expectations. Upon exit, knowledge attained was ranked highest, followed by observation in the operating room, and clinical research experience. All found that the course affirmed their decision to attend medical school and promoted their interest in surgery residency. We demonstrate a successful model for outreach in surgery at the undergraduate level that can positively influence interest in a surgical career, especially among women.
Significant reduction of wound infections with daily probing of contaminated wounds: a prospective randomized clinical trial. - Archives of surgery (Chicago, Ill. : 1960)
Local wound management using a simple wound-probing protocol (WPP) reduces surgical site infection (SSI) in contaminated wounds, with less postoperative pain, shorter hospital stay, and improved patient satisfaction.Prospective randomized clinical trial.Academic medical center.Adult patients undergoing open appendectomy for perforated appendicitis were enrolled from January 1, 2007, through December 31, 2009.Study patients were randomized to the control arm (loose wound closure with staples every 2 cm) or the WPP arm (loosely stapled closure with daily probing between staples with a cotton-tipped applicator until the wound is impenetrable). Intravenous antibiotic therapy was initiated preoperatively and continued until resolution of fever and normalization of the white blood cell count. Follow-up was at 2 weeks and at 3 months.Wound pain, SSI, length of hospital stay, other complications, and patient satisfaction.Seventy-six patients were enrolled (38 in the WPP arm and 38 in the control arm), and 49 (64%) completed the 3-month follow-up. The patients in the WPP arm had a significantly lower SSI rate (3% vs 19%; P = .03) and shorter hospital stays (5 vs 7 days; P = .049) with no increase in pain (P = .63). Other complications were similar (P = .63). On regression analysis, only WPP significantly affected SSI rates (P = .02). Age, wound length, body mass index, abdominal circumference, and diabetes mellitus had no effect on SSI. Patient satisfaction at 3 months was similar (P = .69).Surgical site infection in contaminated wounds can be dramatically reduced by a simple daily WPP. This technique is not painful and can shorten the hospital stay. Its positive effect is independent of age, diabetes, body mass index, abdominal girth, and wound length. We recommend wound probing for management of contaminated abdominal wounds.
Acute respiratory distress syndrome in nontrauma surgical patients: a 6-year study. - The Journal of trauma
Acute respiratory distress syndrome (ARDS) has been shown to increase morbidity but not mortality in trauma patients; however, little is known about the effects of ARDS in nontrauma surgical patients. The purpose of this study is to evaluate the risk factors for and outcomes of ARDS in nontrauma surgical patients.A prospective observational study was performed in the surgical intensive care unit (ICU) of an academic tertiary care center. From 2000 to 2005, all nontrauma surgical admissions to the surgical ICU were evaluated daily for ARDS based on predefined diagnostic criteria. Logistic regression analysis identified independent predictors for ARDS and ICU mortality.Of 2,046 patient identified, 125 (6.1%) met criteria for ARDS. The incidence of ARDS declined annually from 12.2% to 2.1% during the study period (p < 0.001). ARDS patients were significantly older (55.4 years vs. 51.8 years, p = 0.014) and more likely to be obese (32% vs. 22%, p = 0.007) than the non-ARDS population. Independent predictors of ARDS included use of pressors (relative risk, RR = 3.30), sepsis (RR = 1.72), and body mass index >or=30 kg/m (RR = 1.57). Independent predictors of ICU mortality included ARDS (RR = 6.88), pressors (RR = 2.85), positive fluid balance (RR = 2.27), Acute Physiology and Chronic Health Evaluation II (RR = 1.04), and age (RR = 1.02).Unlike trauma patients, ARDS was an independent predictor of ICU mortality in nontrauma surgical patients, independent of age and disease severity. Nontrauma surgical patients who developed ARDS were older, sicker, and had a longer ICU stay. Independent predictors of ARDS included use of pressors, sepsis, and obesity.
The conundrum of the gram-positive rod: are we missing important pathogens in complicated skin and soft-tissue infections? A case report and review of the literature. - Surgical infections
The designation "gram-positive bacillus" includes a variety of pleomorphic microorganisms, including diphtheroids, coryneform species, coccobacilli, and other small rods. Despite differing greatly in their virulence, sources, and even genus, these microscopically similar organisms are often difficult to differentiate without genetic testing.We present a patient with necrotizing fasciitis and a review of the literature to exemplify and assess the scope of this diagnostic conundrum. Cultures taken intra-operatively during surgical debridement grew Morganella morganii and "diphtheroids." Given the low virulence of both organisms, the diphtheroids were reexamined microscopically and assayed for enzymatic activity. Genetic sequence analysis of 16S ribosomal ribonucleic acid (rRNA) was required for species identification.Microscopic inspection identified small, non-spore-forming, gram-positive rods, arranged in clusters, that formed circular, smooth colonies. These were facultatively anaerobic, catalase-negative, non-hemolytic, and unable to reduce nitrates. Standard techniques and assays were unable to identify our organism to species. Ultimately, 16S rRNA gene sequencing of 833 base pairs achieved a 99.04% species match to Arcanobacterium bernardiae.At our facility, diphtheroids are generally considered non-pathogenic contaminants in skin and soft tissue infections. The finding of A. bernardiae in necrotizing fasciitis is unusual and clinically important but would have been missed using conventional methods. As the "gram-positive bacillus" comes to include an ever-increasing number of organisms, genetic sequencing will probably be required more regularly for species identification. Furthermore, given that these genera are similar, often mistaken as contaminants, and difficult to differentiate using standard assays, they may often be missed and are possibly a more-frequent cause of complicated skin and soft tissue infections than the literature would suggest.
A new and standardized approach for trocar placement in laparoscopic Roux-en-Y gastric bypass. - Surgical endoscopy
Super-morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) present unique technical challenges. In our experience the ease of the operation and the operative time seem to be more dependent on body habitus than body mass index (BMI). We hypothesized that the distance between the xyphoid process and the umbilicus (the XU distance) correlated with surgical difficulty and described an original modification of trocar placement based on this measurement to improve the ease of the operation.Seven hundred and seventy-four patients underwent LRYGB, and the XU distance was measured in a subset of 38 patients midway through the experience. The need for additional trocars was assessed intraoperatively and the relationship between the XU distance and the need for extra trocars was subsequently analyzed. A standardized approach for trocar placement was implemented in the second half of our series. The operative time was compared between the standardized and nonstandardized groups.Fifty percent of the patients required a five-trocar technique. Median XU distance in this group was 21.4 cm (range 17-25 cm). In the remaining 19 patients additional trocars were added; median XU distance was 27.3 cm (range 24-33 cm). From the 774 patients included in the study period, the operative time for the first 322 patients who were completed with a nonstandardized trocar approach was significantly longer than the subsequent 452 cases in which the standardized trocar approach was used (210 versus 173 min, p < 0.001).We define XU distance as the key element in determining the choice of trocar placement. When XU distance is less then 25 cm, the basic approach should be used and if it is greater than 25 cm, the advanced trocar approach is recommended. This standardized technique leads to decreased operative time and improved ease of operation.
Planned early discharge-elective surgical readmission pathway for patients with gallstone pancreatitis. - Archives of surgery (Chicago, Ill. : 1960)
We assessed outcomes in patients with gallstone pancreatitis (GSP) managed using a readmission pathway of discharge from the index admission with early readmission cholecystectomy and compared these with conventional management. We hypothesized that the pathway would decrease hospital length of stay (LOS).Prospective cohort study.County-based academic center.All patients admitted with GSP between June 1, 2005, and June 30, 2007. The control group consisted of patients from the year before the adoption of the readmission pathway. The pathway group patients were enrolled in the first year from its inception (July 1, 2006).Overall LOS, time from admission until operation, and pathway failures.Of 252 patients with GSP, 144 were managed by conventional methods, and 108 were managed using the readmission pathway. The overall mean (SD) LOS was 8.5 (6.0) days in the control group and 5.9 (3.1) days in the pathway group (P < .001). The mean (SD) times to surgery were 6.6 (4.5) days in the control group and 22.7 (10.4) days in the pathway group (P =.01). This did not lead to significantly more treatment failures, with 34 (23.6%) in the control group and 33 (30.6%) in the pathway group (P =.21). There were 6.5%(7 of 108) unplanned readmissions for recurrent pancreatitis in the pathway group. Morbidity was otherwise similar in both groups.Use of the readmission pathway's early discharge protocol decreased overall LOS and in this study population was not associated with any increase in morbidity compared with conventional management.
Significant reduction in incidence of wound contamination by skin flora through use of microbial sealant. - Archives of surgery (Chicago, Ill. : 1960)
Application of skin sealant prior to incision reduces microbial contamination of the wound.Prospective, randomized, multicenter clinical trial.Six teaching hospitals.A total of 177 adult patients undergoing elective open inguinal hernia repair were randomized to either standard skin preparation with 10% povidone-iodine or skin preparation followed by cyanoacrylate-based liquid microbial sealant.Wound contamination was assessed during surgery by microbial sampling inside the wound at initiation of skin incision and prior to skin closure.The primary outcome measures were the safety and effectiveness of cyanoacrylate-based microbial sealant to reduce bacterial contamination during surgery. The secondary outcome measure was reduction of postoperative surgical site infections using microbial sealant.Demographics were similar. Patients treated with sealant were more likely to have no bacterial cells found in the wound than control participants (47% vs 31%; P = .04). Three patients developed surgical site infections; all were in the control group (P = .25). Independent factors that reduced wound contamination were use of microbial sealant (odds ratio, 0.45; confidence interval, 0.23-0.88; P = .02) and perioperative antibiotics (odds ratio, 0.24; confidence interval, 0.10-0.58; P = .001).Cyanoacrylate-based microbial sealant may be an important tool to reduce wound contamination and potentially prevent surgical site infections.
Psoas abscess rarely requires surgical intervention. - American journal of surgery
Surgeons are increasingly encountering psoas abscesses.We performed a review of 41 adults diagnosed and treated for psoas abscess at a county hospital. Treatment modalities and outcomes were evaluated to develop a contemporary algorithm.Eighteen patients had a primary psoas abscess, and 23 had a secondary psoas abscess. Patient characteristics were similar in both groups. Intravenous drug abuse was the leading cause of primary abscesses. Secondary abscesses developed most commonly after abdominal surgery. Treatment was via open drainage (3%), computed tomography-guided percutaneous drainage (63%), or antibiotics alone (34%). Four recurrences occurred in the percutaneous group. Statistical analysis showed that the median size of psoas abscesses in the percutaneous group was significantly larger than in the antibiotics group (6 vs 2 cm; P < .001). The mortality rate was 3%.Initial management of psoas abscesses should be nonsurgical (90% success). Small abscesses may be treated with antibiotics alone, and surgery can be reserved for occasional complicated recurrences.
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450 N Roxbury Dr Suite 224 Beverly Hills, CA 90210
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