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Introduction After bariatric surgery, patients often experience redundant skin in the upper arms and medial thighs as sequelae of massive weight loss. Insurance companies have unpredictable criteria to determine the medical necessity of brachioplasty and thighplasty, which are often ascribed as cosmetic procedures. We evaluated current insurance coverage and characterized policy criteria for extremity contouring in the postbariatric population. Methods We conducted a cross-sectional analysis of insurance policies for coverage of brachioplasty and thighplasty in January 2019. Insurance companies were selected based on their state enrolment data and market share. A web-based search and direct calls were conducted to identify policies. A comprehensive list of standard criteria was compiled based on the policies that offered coverage. Results Of the 56 insurance companies assessed, half did not provide coverage for either procedure (n = 28). No single criterion featured universally across brachioplasty and thighplasty policies. Functional impairment was the most commonly cited condition for preapproval of brachioplasty and/or thighplasty (94%). Conversely, minimum weight loss was the least frequent criterion within the insurance policies (6%). Only 5% of the insurance companies (n = 3) would consider coverage of liposuction-assisted lipectomy as a modality for brachioplasty or thighplasty. Conclusions We propose a comprehensive list of reporting recommendations to help optimize authorization of extremity contouring in the postbariatric population. There is great intercompany variation in preapproval criteria for brachioplasty and thighplasty, illustrating an absence of established recommendations or guidelines. High-level evidence and investigations are needed to ascertain validity of the limited coverage criteria in current use.

Heterotopic ossification (HO), or the pathologic formation of bone within soft tissues, is a significant complication following severe injuries as it impairs joint motion and function leading to loss of the ability to perform activities of daily living and pain. While soft tissue injury is a prerequisite of developing HO, the exact molecular pathology leading to trauma-induced HO remains unknown. Through prior investigations aimed at identifying the causative factors of HO, it has been suggested that additional predisposing factors that favor ossification within the injured soft tissues environment are required. Considering that chondrocytes and osteoblasts initiate physiologic bone formation by depositing nanohydroxyapatite crystal into their extracellular environment, we investigated the hypothesis that deposition of nanohydroxyapatite within damaged skeletal muscle is likewise sufficient to predispose skeletal muscle to HO. Using a murine model genetically predisposed to nanohydroxyapatite deposition (ABCC6-deficient mice), we observed that following a focal muscle injury, nanohydroxyapatite was robustly deposited in a gene-dependent manner, yet resolved via macrophage-mediated regression over 28 days post injury. However, if macrophage-mediated regression was inhibited, we observed persistent nanohydroxyapatite that was sufficient to drive the formation of HO in 4/5 mice examined. Together, these results revealed a new paradigm by suggesting the persistent nanohydroxyapatite, referred to clinically as dystrophic calcification, and HO may be stages of a pathologic continuum, and not discrete events. As such, if confirmed clinically, these findings support the use of early therapeutic interventions aimed at preventing nanohydroxyapatite as a strategy to evade HO formation. Electronic supplementary material The online version of this article (10.1007/s00223-018-0502-5) contains supplementary material, which is available to authorized users.

Background: The perceived benefit of utilizing patients' own imaging studies as a preoperative educational tool has not been studied. Methods: Pancreaticobiliary surgeons reviewed key findings of imaging studies with patients to educate about their diagnosis and inform treatment recommendations. Patient surveys were administered pre- and postvisit by an independent researcher to assess the impact of this practice. Results: Only 55% of patients stated that it was important to see their imaging studies before the consultation. However, after the visit, 90% of patients understood their disease process better, and 86% of patients had a clearer understanding of their planned operation having seen their imaging studies. This represents significant improvement in patients' understanding of their medical condition (p

Background: Metastases of renal cell carcinoma (RCC) to the pancreas are rare, whereas recurrence of pancreatic ductal adenocarcinoma (PDA) or a primary periampullary cancer is far more common. The time elapsed between a primary tumor and a new mass can aid in differentiation between the two. Presentation: A 70-year-old man with a history of RCC status after left nephrectomy and ampullary adenocarcinoma status after pancreaticoduodenectomy presents with an incidentally found mass in his remnant pancreas. Resection of the mass via completion pancreatectomy yielded pathology consistent with metastatic RCC. Conclusions: Metastases of RCC to the pancreas often present many years after a primary resection. Conversely, recurrent PDA often presents within 5 years of resection. Resection of RCC metastases yields better survival than resection of recurrent PDA, which is controversial. We recommend resection of suspected isolated pancreatic RCC metastases due to known favorable outcomes.

Background/Purpose Pediatric colonic volvulus is both rare and underreported. Existing literature consists only of case reports and small series. We present an analysis of cases (n = 11) over 15 years at a single institution, focusing on workup and diagnosis. Methods This was an institutional review board approved single-institution retrospective chart review of 11 cases of large bowel volvulus occurring over 15 years (2000–2015). Results In our series, the most common presenting symptoms were abdominal pain and distention. Afflicted patients often had prior abdominal surgery, a neurodevelopmental disorder or chronic constipation. Of the imaging modalities utilized in the 11 patients studied, colonic volvulus was correctly diagnosed by barium enema in 100% of both cases, CT in 55.6% of cases and by plain radiography of the abdomen in only 22.2%of cases. Colonic volvulus was confirmed by laparotomy in all cases. The cecum (n = 5) was the most often affected colonic segment, followed by the sigmoid (n = 3). Operative treatment mainly consisted of resection (63.6%) and ostomy creation (36.4%). Colopexy was performed in 18.2% of cases. Conclusions Plain abdominal radiography may be performed as an initial diagnostic study, however, it should be followed CT or air or contrast enema in children where there is high clinical suspicion and who do not have indications for immediate laparotomy. CT may be the most specific and useful test in diagnosis of colonic volvulus and has the added advantage of detection of complications including bowel ischemia. We demonstrate a range of diagnostic and therapeutic modalities for pediatric colonic volvulus. This underscores the need for further study to draft standard best practices for this life-threatening condition. Level of Evidence Prognosis Study: Level IV. Study of a Diagnostic Test: Level III.

Pseudoxanthoma elasticum (PXE), a heritable ectopic mineralization disorder, is caused by mutations in the ABCC6 gene primarily expressed in the liver and the kidneys. The fundamental question on pathogenesis of PXE, whether lack of ABCC6 expression in liver or kidney is the primary site of molecular pathology in peripheral tissues, has not been addressed. We generated a series of Abcc6−/− rats as models of PXE depicting ectopic mineralization in the skin, eyes, and the arterial blood vessels. Plasma PPi level was reduced (

Surgical site infections (SSIs) cause significant patient morbidity and increase costs. This work prospectively examines our institutional effort to reduce SSIs through a resident-driven quality initiative.A general surgery resident-championed, evidenced-based care bundle for patients undergoing colorectal surgery at a single academic institution was developed using attending mentorship. National Surgical Quality Improvement Program definitions for SSIs were used. Data were collected prospectively and bundle compliance was monitored using a checklist. The primary outcome compared SSIs before and after implementation.In the 2 years preceding standardization, 489 colorectal surgery cases were performed. SSIs occurred in 68 patients (13.9% SSI rate). Following implementation of the bundle, 212 cases were performed with 10 SSIs (4.7% SSI rate, P.01). Multivariate logistic regression analysis found a decrease in superficial and overall SSIs (odds ratio .17, 95% confidence interval .05 to .59; odds ratio .31, 95% confidence interval .14 to .68).These data demonstrate that resident-driven initiatives to improve quality of care can be a swift and effective way to enact change. We observed significantly decreased SSIs with a renewed focus on evidence-based, standardized patient care.

Background: Pancreatic neuroendocrine tumors (PNETs) are relatively rare, and data guiding management of metastatic lesions are scarce. Hepatic metastases are most common; here we describe a case of metastatic PNET implanted into the posterior gastric cardia. Case Presentation: This case study describes the progression of a 44-year-old man with a history of pancreatic neuroendocrine tumor (PNET) resected through distal pancreatectomy and splenectomy who developed recurrent disease in his stomach with extension into the left adrenal fossa 17 months after initial resection. He subsequently underwent a total gastrectomy and left adrenalectomy with en bloc resection of this recurrence without complication. Final pathology revealed a morphologically similar PNET with positivity for CAM5.2, chromogranin A, and synaptophysin. Conclusion: The unusual location of his recurrence could suggest that his preoperative endoscopic ultrasound and fine-needle aspiration may have had a role in seeding the posterior gastric wall, highlighting the risk of performing this diagnostic procedure in the setting of suspected pancreatic malignancy.

Suture and needles are the most essential equipment for the surgeon. Their structure and design have evolved thoroughly in the era of modern surgery. Suture varies based on its physical properties including material, construction, absorbability, size, tensile strength, length, and color. Similarly, needles vary in their point type, curvature, strength, length, and color. An array of combinations of sutures and needles has been created with specific surgical tasks in mind. While there is no ultimate suture that will work in any circumstance, certain guiding principles allow the surgeon to choose the best option. Our aim in this chapter is to provide information on the physical properties of suture and needles so that individuals feel comfortable calling for the proper suture for any surgical task.