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Various risk score calculators used to predict 30-day mortality after treatment of ruptured abdominal aortic aneurysms (rAAAs) have produced mixed results regarding their usefulness and reproducibility. We prospectively validated the accuracy of our preoperative scoring system in a modern cohort of patients with rAAAs.A retrospective review of all patients wiith rAAAs who had presented to a single academic center from January 2002 to December 2018 was performed. The patients were divided into three cohorts according to when the institutional practice changes had occurred: the pre-endovascular aneurysm repair (EVAR) era (January 2002 to July 2007), the pre-Harbor View risk score era (August 2007 to October 2013), and the modern era (November 2013 to December 2018). The primary outcome measure was 30-day mortality. Our preoperative risk score assigns 1 point for each of the following: age76 years, pH 7.2, creatinine2 mg/dL, and any episode of hypotension (systolic blood pressure 70 mm Hg). The previously reported mortality from a retrospective analysis of the first two cohorts was 22% for 1 point, 69% for 2 points, 78% for 3 points, and 100% for 4 points. The goal of the present study was to prospectively validate the Harborview scoring system in the modern era.During the 17-year study period, 417 patients with rAAAs were treated at our institution. Of the 118 patients treated in the modern era, 45 (38.1%) had undergone open aneurysm repair (OAR), 61 (51.7%) had undergone EVAR, and 12 (10.2%) had received comfort measures only. Excluding the 12 patients without aneurysm repair, we found a statistically significant linear trend between the preoperative risk score and subsequent 30-day mortality for all patients combined (P .0001), for OAR patients alone (P = .0003), and for EVAR patients alone (P .0001). After adjustment for the Harborview risk score, the 30-day mortality was 41.3% vs 31.6% after OAR vs EVAR, respectively (P = .2). For all repairs, the 30-day mortality was 14.6% for a score of 0, 35.7% for a score of 1, 68.4% for a score of 2, and 100% for a score of 3 or 4.Our results, representing one of the largest modern series of rAAAs treated at a single institution, have confirmed the accuracy of a simple 4-point preoperative risk score in predicting 30-day mortality in the modern rAAA patient. Such tools should be used when discussing the treatment options with referring physicians, patients, and their family members to help guide transfer and treatment decision-making.

Inguinal ultrasound (US) has a high sensitivity and specificity for the diagnosis of inguinal hernias but is often performed unnecessarily, adding cost and time to treatment. The aim of our study was to assess the rate and necessity of US before clinical examination by a hernia surgeon. Medical records of patients referred for an inguinal hernia from April through July 2017 were reviewed. These cases were analyzed for patient demographics, physical examination (PE) findings, previsit imaging, health-care system of surgeon, and case outcome. Twenty-nine per cent of patients had an inguinal US before visiting a surgeon. Sixty-three per cent of patients who underwent an US had a palpable hernia on PE, and 76 per cent had a positive PE by the surgeon. Patients without a hernia on referring provider's PE underwent US 59 per cent of the time. Inguinal USs are being ordered unnecessarily by referring providers. Physical examination by referring providers and surgeons should be the primary tool for diagnosis of an inguinal hernia.

Hydrophilic polymer coatings are now widely applied to catheters and other intravascular devices used in neurovascular, cardiovascular, and peripheral vascular procedures. Emboli consisting of these materials have been previously identified in biopsies and autopsies following pulmonary infarction, stroke, gangrene, or death. We report a case involving a nonhealing foot ulcer that appeared following cardiac catheterization, stenting, and automatic implanted cardiac defibrillator (AICD) implantation in a patient without other evidence of significant peripheral artery disease. An 85-year-old woman with chronic atrial fibrillation, aortic valve stenosis, and coronary artery disease underwent coronary stenting and AICD implantation for ventricular tachycardia and syncope. She developed a toe ulcer shortly thereafter, which did not respond to standard treatment. A histological examination following amputation of the toe found amorphous basophilic material in capillaries adjacent to the edge of the ulcer, which was similar to material associated with hydrophilic polymer coatings. Ischemia and infarcts following endovascular procedures should not be presumed to result from thrombus or vascular disease, even if intravascular devices appear intact or properly placed after the procedure. To help establish the incidence of ischemia caused by hydrophilic polymer device coatings, if excision of ischemic or infarcted tissue after endovascular procedures using coated devices becomes necessary, the tissue should be evaluated microscopically. Surgeons should also consider the tolerance of distal organs to infarct or ischemia when selecting coated intravascular devices.

Endovascular embolization of visceral arteries is commonly performed as treatment for aneurysms, pseudoaneurysms, and emboloradiation of liver tumors; while considered relatively safe, it is not without complications. We are reporting 2 cases of coil migration into the gastrointestinal tract. Patients were successfully managed without endoscopic or surgical coil removal. Patients were followed after discharge and noted to have no further complications from their migrated coils. These cases highlight the success of expectant management for coil migration. We recommend against invasive intervention for coil removal as first-line treatment for endovascular coil migration into the intestinal tract. We urge providers to weigh the risks and benefits of coil removal, prior to invasive intervention.

Early cholecystectomy following an episode of gallstone pancreatitis is data supported, however, there is minimal literature regarding the optimal timing for cholecystectomy following an episode of acute cholangitis. Our study aims to determine the ideal timing for laparoscopic cholecystectomy following an episode of acute cholangitis. A retrospective chart review was done on cholecystectomies performed for cholangitis at our institution from 2008 to 2015. Patients were compared based on timing of cholecystectomy (i.e., index admission versus delayed) and Tokyo severity grade (I–III). We identified 151 patients who underwent cholecystectomy for cholangitis at our institution from 2008 to 2015. Cholecystectomy was performed during the index admission for 61.6% of patients and Tokyo grade (TG) did not affect the rate of cholecystectomy during index admission (TG1 65.2%, TG2 64.1%, TG3 52.8%; p = 0.46). There was no difference in average operative time (89.0 min vs. 96.6 min; p = 0.36) or conversion to open cholecystectomy (5.4% vs. 10.3%; p = 0.34) between early and late cholecystectomy groups. There was also no statistically significant difference in intra-operative complications (9.7% vs. 15.5%; p = 0.28) or overall complication rates (16.1% vs. 29.3%; p = 0.05) based on timing of cholecystectomy; however, post-operative complications were significantly higher for the delayed cholecystectomy group (20.7% vs. 6.5%; p = 0.01). Early cholecystectomy after cholangitis is safe to perform and is not associated with higher operative times or rate of conversion to open, regardless of Tokyo grade. Due to the risk of developing recurrent cholangitis and a higher rate of post-operative complications seen with delayed cholecystectomy, our recommendation is to perform cholecystectomy during the index admission.

Aspergillus is a rare cause of surgical site infection most often seen in immunocompromised patients undergoing cardiac, transplant, ophthalmologic, or burn operations; an unusual case following a colon resection is presented here.The authors report a case of an invasive Aspergillus fumigatus infection following a subtotal colectomy for toxic megacolon. The patient was on antibiotics following the operation and chronic immunosuppression with steroids and infliximab. This was an unusual cause of a postoperative wound infection.This case highlights the importance of early and accurate identification, debridement, and systemic antifungals to prevent widespread infection. With changes in antifungal care over recent years, engaging infectious disease physicians during treatment is recommended.