Chapital, Alyssa B.

Summary: Pleuroperitoneal (Denver) shunts have been used primarily for palliation of refractory malignant and chylous peritoneal and pleural collections. 1–5 We used a pleuroperitoneal (Denver) shunt for a recurrent, nonmalignant breast seroma in the palliation of metastatic breast cancer as a novel use of this shunt.

Jejunal diverticulosis is a rare condition that is usually found incidentally. It is most often asymptomatic but presenting symptoms are nonspecific and include abdominal pain, nausea, diarrhea, malabsorption, bleeding, obstruction, and/or perforation. A retrospective review of medical records between 1999 and 2012 at a tertiary referral center was conducted to identify patients requiring emergency management of complicated jejunal diverticulosis. Complications were defined as those that presented with inflammation, bleeding, obstruction, or perforation. Eighteen patients presented to the emergency department with acute complications of jejunal diverticulosis. Ages ranged from 47 to 86 years (mean, 72 years). Seven patients presented with evidence of free bowel perforation. Six had either diverticulitis or a contained perforation. The remaining five were found to have gastrointestinal bleeding. Fourteen of the patients underwent surgical management. Four patients were successfully managed nonoperatively. As a result of the variety of presentations, complications of jejunal diverticulosis present a diagnostic and therapeutic challenge for the acute care surgeon. Although nonoperative management can be successful, most patients should undergo surgical intervention. Traditional management dictates laparotomy and segmental jejunal resection. Diverticulectomy is not recommended as a result of the risk of staple line breakdown. The entire involved portion of jejunum should be resected when bowel length permits.

Appendicitis is a common diagnosis encountered by the acute care surgeon. Management of complicated appendicitis is controversial and often involves initial nonoperative therapy with interval appendectomy. This study reviews single-institutional experience with management of complicated appendicitis with interval appendectomy and addresses an unusually high occurrence of incidental appendiceal malignancies observed with a review of relevant literature. A retrospective review of all diagnoses of appendicitis was performed over 5 years at a tertiary care center. Patient demographics, time to surgery, operative technique, pathologic diagnosis, and clinical outcomes were examined. Three hundred fifteen patients were diagnosed with acute appendicitis. Of these, 24 (7.6%) were deemed complicated and did not undergo immediate appendectomy, and 18 ultimately underwent appendectomy at our institution and were included in analysis. There were no statistical demographic or symptomatic differences between the immediate and interval appendectomy patients. Ninety-nine per cent of the immediate appendectomy patients were treated laparoscopically; 78 per cent of the interval group underwent attempted laparoscopic treatment with 56 per cent completed without conversion to open ( P < 0.01). Neoplasms were discovered in 1 per cent of the acute appendectomy group and 28 per cent of the interval appendectomy group ( P < 0.0001). Two of the three neoplasms in the acute group were carcinoid, whereas three of the five neoplasms in the interval group were adenocarcinoma. Surgeons should consider appendiceal or colonic neoplasms in cases of complicated appendicitis when nonoperative management is considered. This is most important in patients older than 40 years, in those who forego interval appendectomy, or in those who could be lost to follow-up.

Successful dialysis access necessitates superficial arteriovenous fistula (AVF) placement to facilitate identification of anatomical landmarks for safe cannulation. Suction-assisted lipectomy (SAL) may be an alternative to traditional surgical AVF revision procedures for placing fistulas more superficially. Three patients with an average body mass index of 45.2 kg/m 2 , with inaccessible AVFs due to obesity, underwent ultrasound-guided SAL of their upper extremities. Successful cannulation was achieved within two weeks. A clinically insignificant hematoma and arm swelling occurred in one patient. SAL provides a safe and effective alternative for salvaging deep AVFs for dialysis access in the upper extremities of obese patients.

Coronary artery dissection is an infrequent cause of acute coronary syndrome in the general population. There is, however, a greater incidence of spontaneous coronary artery dissection (SCAD) in young women, especially in the peripartum period. However, the majority of cases have favorable outcomes with medical management or percutaneous coronary intervention; coronary artery bypass grafting (CABG) and transplantation are utilized in severe cases. This case is a one of a 30-year-old postpartum female with multivessel SCAD requiring CABG with subsequent biventricular failure and inability to wean from bypass. We believe this is the first reported case in which venoarterial extracorporeal membrane oxygenation (VA-ECMO) was used in the management of biventricular heart failure in a postpartum patient with SCAD.

Objectives. Increasing number of mechanical circulatory assist devices (MCADs) are being placed in heart failure patients. Morbidity from device placement is high and the outcome of patients who require noncardiac surgery after, is unclear. As laparoscopic interventions are associated with decreased morbidity, we examined the impact of such procedures in these patients. Methods. A retrospective review was conducted on 302 patients who underwent MCAD placement from 2005 to 2012. All laparoscopic abdominal surgeries were included and impact on postoperative morbidity and mortality studied. Results. Ten out of 16 procedures were laparoscopic with 1 conversion to open. Seven patients had a HeartMate II, 2 had Total Artificial Hearts, and 1 had CentriMag. Four patients had devices for ischemic cardiomyopathy and 6 cases were emergent. Surgeries included 6 laparoscopic cholecystectomies, 2 exploratory laparoscopies, 1 laparoscopic colostomy takedown, and 1 laparoscopic ventral hernia repair with mesh. Median age of the patients was 63 years (range, 29-79 years). Median operative time was 123 minutes (range, 30-380 minutes). Five of 10 patients were on preoperative anticoagulation with average intraoperative blood loss of 150 mL (range, 20-700 mL). There were 3 postoperative complications; acute respiratory failure, acute kidney injury and multisystem organ failure resulting in death not related to the surgical procedure. Conclusion. The need for noncardiac surgery in post-MCAD patients is increasing due to limited donors and due to more durable and longer support from newer generation assist devices. While surgery should be approached with caution in this high-risk group, laparoscopic surgery appears to be a safe and successful treatment option.