Significance of vesicles in flap monitoring in oral cancer surgery: Report of two cases

The success rate of vascularized free flap transplantation in head and neck oncologic surgery is high, ranging from 94% to 98.8%; however, flap necrosis sometimes occurs after surgery. When vessel-related complications occur, flap necrosis proceeds rapidly. Thus, flap monitoring after surgery is especially important. We recently treated two patients with flap-related complications. A vesicle appeared on the surface of the flap and enlarged within a short time; the flap’s color changed to purple, and a reoperation was eventually performed. While there are approaches to monitor flaps, this is the first report suggesting the assessment of vesicle formation for flap monitoring, since the vesicles occur several hours before changes in the flap color.

Unilateral congenital lunate absence: A case report

Isolated congenital aplasia of carpal bones in the absence of an associated congenital syndrome is exceedingly rare. Since the first documented case report of congenital carpal bone absence in 1911, only 12 additional case reports have been published. Here we present a case report of an otherwise healthy 43-year-old male with unilateral congenital absence of the lunate, which has only been previously reported once in the literature.

Posterior chest wall reconstruction: A novel approach

Traditional access for open reduction internal fixation (ORIF) of posterior rib fractures occurs through either a posterior lateral thoracotomy or posterior paramedian approach. We report the case of severe blunt chest wall injury reconstruction using the novel implementation of an Opening Wedge Thoracostomy (OWT) approach. This approach is conventionally indicated for expansion thoracostomy in the surgical management of scoliosis. The OWT approach facilitates chest wall reconstruction vis-a-vis reflection of the trapezius and latissimus dorsi muscles providing excellent exposure of the posterior thoracic cage facilitating surgical reduction and fixation. Satisfactory stability of the posterior chest is not achievable using previously described approaches. OWT approach exposure for posterior thoracic reconstruction absents the surveyed literature.

A case series of a novel phenomenon of “whiplash bladder”

We describe the phenomenon of the development of lower urinary tract symptoms (storage) following accidents in which there is no direct bladder trauma or pelvic fracture and propose the term “Whiplash bladder”. That bladder symptoms may develop in such circumstances is under appreciated in the urological and medical legal literature.

Day late and dollar short! Delayed recurrence of recto-sigmoid cancer involving sacrum and long term surveillance

Patients with colorectal cancer will develop recurrence of the disease with greater than 90% having it in the first 5 years following surgery. If detected early, may be amenable to potentially curative surgical resection. This provides the rationale for a follow-up strategy in patients with resected colorectal cancer. We report a case of a 68-year-old female who had a loco regional recurrence after 13 years of primary surgery involving the middle part of sacrum, raising the question regarding the long term surveillance.

Trapeziometacarpal joint arthritis: A retrospective study of the natural history of symptomatic thumb arthritis

Objective: Trapeziometacarpal (TM) joint arthritis is a common source of hand pain in patients presenting to the hand surgeon’s clinic. Long-term data on the natural history of symptomatic TM arthritis is lacking.Methods: We identified 251 patients with symptomatic TM arthritis and performed a retrospective chart review which identified treatment modalities (including surgery) and long term outcomes which were assessed via a telephone survey.Results: We found that of the 251 patients who presented with symptomatic TM arthritis, the 114 patients who had surgery had less pain and disability in the long term than those patients who were treated conservatively with splinting or injection (average pain score 1.8 vs. 3.8). However, the majority of patients did not ultimately undergo surgery.Conclusions: Although patients fare better from a pain and function standpoint with surgery, surgery is not inevitable.

Brief report: De Garengeot’s hernia

We describe a case of a 70-year-old female who presented with pain and swelling in her right groin. CT scan of the abdomen and pelvis found Amyand’s hernia with evidence of inflammation of the appendiceal tip consistent with appendicitis. Laparoscopic appendectomy and open hernia repair revealed an incarcerated hernia. Using blunt dissection, the inflamed tip of the appendix was found in the femoral canal. The appendix was removed. The patient had a De Garengeot’s hernia, not the Amyand’s hernia initially suspected. Patient was discharged home the following day.

Thoracic epidural analgesia vs. intravenous analgesia after lung transplant

Objective: Few reports have evaluated postoperative continuous thoracic epidural analgesia on patients who received a lung transplant. This analgesic modality may facilitate extubation, early ambulation, and achieve adequate pain control with minimization of opioid use. An opioid sparing technique could minimize the side effects of opioids such as ileus, constipation, and somnolence.Methods: A retrospective chart review following local IRB approval was performed. A total of 97 patients’ charts were collected, from April 2015 to March 2017. Forty-eight patients received T6-7 epidural, and forty-nine patients received standard intravenous (IV) analgesia. Outcome measures collected included length of intensive care unit stay, total duration of hospitalization, need for reintubation or noninvasive intermittent positive pressure ventilation (NIPPV), need for IV lidocaine gtt, and total narcotics consumption during hospitalization in milligrams of morphine equivalents (MME).Results: Both groups were comparable in age, BMI, and race/gender distribution. Additionally, patient pain requirements were comparable between groups. However, a significantly smaller proportion of thoracic epidural patients required NIPPV post-operatively, (20.4%, 53.2%: p = .0015). Further, the number of patients requiring reintubation was almost halved, (12.5%, 21.3%: NS). Patients receiving thoracic epidural also experienced shorter ICU times (p = .0335) and on average, an overall reduced length of stay by six days.Conclusions: For patients undergoing lung transplant, epidural analgesia is a viable alternative to IV pain control. Further, it significantly reduced respiratory depression and length of stay in the ICU. More refined comparisons can be made by conducting a precise prospective study with a more structured protocol in place.

Distinguishing duodenal duplication cyst from choledochocele: A case report

Duodenal duplication cysts (DDC) are a rare type of enteric duplication. We describe the clinical presentation and laparoscopic management of a 7-year-old boy with a periampullary DDC.We also discuss the embryologic and imaging features that distinguish DDC from choledococele (CC). Careful consideration of the anatomic relationships between the ampulla, common bile duct, and duplication cyst are essential to avoid intraoperative bile duct injury.

Sugammadex administration shortens reversal times but not operating room turnover times

Objective: Current literature debates whether administration of sugammadex translates into a higher operating room (OR) efficiency when compared to neostigmine. This study is a blinded assessment of the effects of sugammadex versus neostigmine on OR efficiency as determined by time of reversal to time of the next case.Methods: 50 patients undergoing abdominal surgery were randomized and evenly distributed into two groups, one receiving sugammadex (4 mg/kg) and the other, neostigmine (0.06 mg/kg) plus glycopyrrolate (0.004 mg/kg). Muscle paralysis was induced with intravenous rocuronium (0.6 mg/kg). Train of four (TOF) was monitored using acceleromyography every 10 minutes until reversal. Reversal agents were blindly prepared and administered during closing. TOF was then recorded every minute until a T4/T1 ratio ≥ 0.9 was achieved. This was designated as time of complete reversal. Subsequently, post-reversal outcome measures were collected.Results: Patients receiving sugammadex experienced a significantly shorter reversal time compared to those receiving neostigmine and glycopyrrolate (2.92 ± 1.71 minutes vs. 7.68 ± 5.63 minutes; p = .0002). No other outcome measures were significantly different between groups: time of OR ready for next case was 55.4 min vs. 56.1 min respectively; not significant.Conclusions: While sugammadex was significantly faster at reversing patient neuromuscular blockade the time from reversal to patient extubation after Sugammadex was prolonged. . This could be due to blinding, as blinded providers are unable to anticipate time of reversal and must compensate by making decisions at safe fixed intervals. This is reflected in that the time gained by administration of sugammadex is approximately equal to the delay experienced across all endpoints collected to the patients’ actual discharge.