Search

Injury to the inferior vena cava (IVC) can produce bleeding that is difficult to control. Endovascular balloon occlusion provides rapid vascular control without extensive dissection and may be useful in large venous injuries, especially in the juxtarenal IVC. We describe the procedural steps, technical considerations, and clinical scenarios for using the Bridge occlusion balloon (Philips) in IVC trauma. We present a single-center case series of 5 patients in which endovascular balloon occlusion of the IVC was used for hemorrhage control. All 5 patients were men (median age 35, range 22 to 42 years). They all sustained penetrating injuries—4 gunshot wounds and 1 stab wound. Median presenting Shock Index was 0.7 (range 0.5 to 1.5). Median initial lactate was 5.4 mmol/L (range 4.6 to 6.9 mmol/L). There were 2 suprarenal IVC injuries, 2 juxtarenal injuries, and 3 infrarenal injuries. Four patients underwent primary repair of their injury, and one underwent IVC ligation. Four patients had intraoperative Resuscitative Endovascular Balloon Occlusion of the Aorta for inflow control and afterload support. The median number of total blood products transfused during the initial operation was 37 units (range 16 to 77 units). Four patients underwent damage control operations, and one patient had a single definitive operation. Four of the 5 patients (80%) survived to discharge with the lone mortality being due to other injuries. Endovascular balloon occlusion serves as a valuable adjunct in the management of IVC injury and demonstrates the potential of hybrid open–endovascular operative techniques in abdominal vascular trauma. [ABSTRACT FROM AUTHOR]

Background: A difficult laparoscopic cholecystectomy (LC) confers an increased risk of bile duct injury. Traditionally, surgeons convert to open cholecystectomy (OC) as a bailout procedure for safer dissection. Laparoscopic subtotal cholecystectomy (LSC) has recently gained favor with comparable short-term complication rates, but differences in long-term outcomes remain unknown. We sought to compare long-term biliary outcomes between OC and LSC., Study Design: We performed a single-center retrospective cohort study of adults who underwent non-elective LC converted to OC or LSC due to difficult dissection from 1/1/2015 to 12/31/2019. The primary outcome was a composite measure of postoperative biliary events, and we used time-to-event analysis to compare the 2 groups. We evaluated secondary outcomes using Chi-squared or independent t-tests as appropriate., Results: Of 1089 patients who underwent non-elective LC, 68 (6%) underwent a bailout procedure (30 OC vs 38 LSC). There were no differences in demographics or comorbidities between the groups. Most patients (84%) had acute cholecystitis. Average follow-up times were 40 ∓ 29 months in OC and 54 ∓ 21 months in LSC. Biliary events occurred in 13 total patients (19%) with OC most commonly suffering bile leak (17%) and LSC most commonly having choledocholithiasis (11%). Kaplan-Meier analysis demonstrated no significant difference in biliary events between the groups ( P = 0.71). Secondary outcomes were all similar between groups, except LSC had a shorter length of stay (2.9 ∓ 2.3 vs 5.1 ∓ 3.6 days, P = 0.002)., Conclusions: OC and LSC demonstrated comparable long-term biliary outcomes. In a difficult LC, surgeons may perform either bailout procedure to safely manage the gallbladder., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Multiple studies have shown the significantly increased post-operative morbidity and mortality of patients undergoing palliative operations. It has been proposed by some authors that the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database can be used reliably to develop risk-calculators or as an aid for clinical decision-making in advanced cancer patients. ACS-NSQIP is a population-based database that by design only captures outcomes data for the first 30-day following an operation. We considered the suitability of these data as a tool for decision-making in the advanced cancer patient., Methods: Six-year retrospective review of a single institution's ACS-NSQIP database for cases identified as "Disseminated Cancer". Procedures performed with palliative intent were identified and analyzed., Results: Of 7,763 patients within the ACS-NSQIP database, 138 (1.8%) were identified as having "Disseminated Cancer". Of the remaining 7,625 entries only 4,486 contained complete survival data for analysis. Thirty-day mortality within the "Disseminated Cancer" group was higher when compared to all other surgical patients (7.9% vs. 0.9%, P<0.001). Explicit chart review of these 138 patients revealed that 32 (23.2%) had undergone operations with palliative intent. Overall survival for palliative and non-palliative operations was significantly different (104 vs. 709 days, P<0.001). When comparing palliative to non-palliative procedures using ACS-NSQIP data, we were unable to detect a difference in 30-day mortality (9.4% vs. 7.5%, P=0.72)., Conclusions: Calculations utilizing ACS-NSQIP data fail to demonstrate the increased mortality associated with palliative operations. Patients diagnosed with advanced cancer are not adequately represented within the database due to the limited number of cases collected. Also, more suitable outcomes measures for palliative operations such as pain relief, functional status, and quality of life, are not captured. Therefore, the sole use of thirty-day morbidity and mortality data contained in the ACS-NSQIP database is insufficient to make sound decisions for surgical palliation.