Baxter, Jacob

Abstract Background: Congenital peritoneal encapsulation (cocoon deformity) is a rare variant of intestinal malrotation. Objectives: To characterize the clinical presentation and outcomes in patients undergoing surgery for intestinal malrotation with cocoon deformity. Design: Retrospective review. Settings: A large tertiary care center, from January 2003 to December 2022. Patients and Methods: All patients who underwent surgery for intestinal malrotation with cocoon deformity were included. Sample Size: Nine patients were identified. Main Outcome Measures: Patient demographics and operative outcomes. Results: Most patients were female (88.9%), with a median age of 37 years (interquartile range [IQR], 19–53). Most were symptomatic upon diagnosis (88.9%), with abdominal pain (77.8%) being the most common symptom. One patient presented acutely, requiring immediate surgical intervention. Computed tomography was the most frequently used modality to establish a diagnosis of intestinal malrotation. A laparoscopic Ladd procedure was attempted in all patients, with three requiring conversion to open surgery. The median operative time was 119 min (IQR, 96.5–202), with a median estimated blood loss of 25 mL (IQR, 15–125). The median length of hospital stay was 2 days (IQR, 1.5–7). The most common postoperative complications were ileus ( n = 3, 33.3%) and 30-day readmission ( n = 3, 33.3%). Most patients experienced partial or complete resolution of symptoms ( n = 7, 77.8%) and no patients required reoperation. The median follow-up duration was 71.8 months (IQR, 21.3–138.7). Conclusions: The laparoscopic Ladd procedure with excision of the cocoon deformity can be performed safely and is associated with significant improvement in preoperative symptoms. Limitations: Cocoon deformity was not diagnosed preoperatively, and there is currently no gold standard imaging modality for its detection.

Background and Objectives: Perineal wound complications and pelvic fluid collections or abscesses following proctectomy for Crohn’s disease are a common cause of morbidity and might be mitigated by filling the pelvis and occluding the pelvic inlet with a flap. Alternative flap options can be considered when inadequate omentum is available and when avoiding myofasciocutaneous flaps. Materials and Methods: A retrospective review of our Crohn’s proctectomy database was conducted to identify patients who underwent a non-omental or non-myofasciocutaneous local pedicle flap to their pelvis or pelvic exclusion using biological material during surgery. The techniques and outcomes of these alternative techniques are described in detail. Results: 228 patients underwent proctectomy for Crohn’s disease during the 10-year study period. However, only six patients had their pelvis filled or pelvic inlet occluded using a non-omental, non-myofasciocutaneous local pedicled flap or biological material. The techniques identified included two sigmoid mesocolic flaps, one peritoneal, preperitoneal fat and falciform ligament flap, one perivesical fat flap, one Gerota’s fat pad flap, and one bovine pericardial patch assisted pelvic exclusion. These flaps’ clinicopathological and operative characteristics, surgical outcomes, and technical aspects are described. Conclusions: When greater omentum is unavailable or inadequate and myofasciocutaneous flaps need to be avoided, local pedicled flaps using a range of intra-abdominal tissues or biological material can be used to fill the pelvis or occlude the pelvic inlet after proctectomy for Crohn’s disease. These techniques may help to prevent short and long-term complications associated with having a pelvic dead space.

Abstract INTRODUCTION: Postoperative stress induced insulin resistance, and the resulting glycemic variability, is clearly associated with complication rates in cardiac surgery. Despite this, there is a paucity of data regarding the duration of stress induced hyperglycemia in cardiac surgery as well as the impact of specific strategies for carbohydrate loading in cardiac surgery patients. Prior work in colorectal and bariatric surgery has shown a significant reduction in glycemic events with the use of a low dose maltodextrin and citrulline loading strategy, but there is no data that the commonly recommended 50 gram supplements provides any impact on stress induced postoperative hyperglycemia. The aim of this study was to compare standard of care (SOC group) versus a three dose, 25 gram dose carbohydrate loading strategy (CL group) on the duration and severity of postoperative glycemic variability in both diabetic and non-diabetic cardiac surgery patients.METHODS: We compared CABG/AVR/MVR retrospective patients who received standard of care (SOC) to a prospective set of patients who were carbohydrate loaded (CL) with 3 preoperative doses of 25g maltodextrin/3g citrulline (G.E.D.TM, SOF Health, LLC).RESULTS: 152 patients total were included (SOC n=80, CL n= 72). 66 patients were diabetic. In both non-diabetic and diabetic patient populations, there was a statistically significant reduction in glycemic variability in G.E.D. groups for non- diabetics (27% reduction) and diabetics (40% reduction). The glycemic variability on POD 2 was not statistically different between treatment groups in non-diabetics (G.E.D. 25.2% vs SOC 24.7%) but approached significance in diabetics (G.E.D. 24.7% vs SOC 32.9%e). CONCLUSION: These are the first data demonstrating the reduction in post operative stress induced glycemic variability in cardiac surgery using a low dose carbohydrate loading regimen which includes the amino acid citrulline. The impact of surgical stress on glycemic variability appears to resolve by POD#2 in non-diabetics but may persist longer in diabetic patients. These data represent the first information regarding the benefits of a specific strategy for carbohydrate loading to reduces the stress induced component of post operative hyperglycemia in cardiac surgery.