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Radiation-induced breast angiosarcoma, or secondary angiosarcoma (SAS), is a rare entity with a high risk of metastatic recurrence. Herein, we describe the use of intraoperative fluorescence-based skin angiography to guide surgical resection following a novel immunotherapy-based regimen for SAS resulting in a complete pathological response.

Vascular reconstruction during pancreaticoduodenectomy is increasingly utilized to improve pancreatic cancer resectability. However, few multi-institutional studies have evaluated the morbidity and mortality of arterial and venous reconstruction during this procedure. A retrospective analysis was performed utilizing the targeted pancreas module of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) for pancreaticoduodenectomy from 2014 to 2015. Demographics, comorbidities, and 30-day outcomes for patients who underwent venous or arterial reconstruction and both were compared to no reconstruction. A total of 3002 patients were included in our study: 384 with venous reconstruction, 52 with arterial, 81 with both, and 2566 without. Compared to patients without reconstruction, those who underwent venous reconstruction had more congestive heart failure (1.8% vs 0.2%, P

A soft pancreas has been associated with an increased risk of post-operative pancreatic fistula formation. Few studies have evaluated the effect of anastomotic technique (duct to mucosa vs invagination) on fistula formation. This study aims to compare the effect of anastomotic technique on fistula formation among patients with a soft pancreas in a large multiinstitutional database. The targeted pancreas module of the American College of Surgeons–National Surgical Quality Improvement Program (NSQIP) Database was used. All patients with a soft pancreas who underwent pancreaticoduodenectomy from 2014 to 2015 were identified. Demographic data, comorbid conditions, operative variables, and 30-day outcomes were compared using univariate and multivariable analyses. A total of 975 patients met inclusion criteria. Eight-hundred fifty four (88%) underwent a duct to mucosa pancreaticojejunostomy technique and 121 (12%) underwent invagination. Patients who underwent invagination had higher 30-day mortality (5.8% vs 1.4%, p

Background Venous thromboembolism, including pulmonary embolism (PE) and deep venous thrombosis, is a leading cause of morbidity and mortality after bariatric surgery. Inferior vena cava filters (IVCFs) have been used as a method to reduce the incidence of clinically significant PEs after bariatric surgery. Objectives To compare the incidence of postoperative PEs in patients with IVCFs with those in patients without IVCFs at the time of bariatric surgery. Setting American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Methods All patients undergoing laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy from 2015 to 2016 were identified within the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Patients with an IVCF present at the time of surgery were compared with those patients without an IVCF present at the time of surgery with respect to preoperative patient variables, operative variables, incidence of 30-day PE, deep venous thrombosis, and additional 30-day morbidity and mortality. Results A total of 286,704 patients met the inclusion criteria; 2512 (.9%) patients had an IVCF present at the time of surgical intervention, of which 1747 (69.5%) were placed within 30 days of bariatric surgery. Patients with an IVCF were higher-risk patients as determined by previously established risk factors for venous thromboembolism events. When a subgroup matched analysis using variables associated with the risk of venous thromboembolism events was performed looking at higher-risk patients only, there was no statistically significant difference in the incidence of PE based on the presence of an IVCF. Conclusion IVCFs are being selectively placed in higher-risk patients. Despite their selective use, IVCFs do not appear to have a protective benefit with respect to the incidence of postoperative PE events.

BACKGROUND Devascularization of the nipple-areola complex (NAC) before nipple-sparing mastectomy (NSM) enhances blood flow to the skin. This study analyzed the effect of the interval between stages in two-stage (2S) operations and compared the ischemic events with those of one-stage (1S) NSM. METHODS Ischemic complications were defined as partial/reversible (PR) or full-thickness/irreversible (FI) skin necrosis of the NAC or flap. The latter encompassed limited areas of the NAC, resulting in loss of nipple height or areolar circumference without affecting the integrity or appearance of the NAC. Outcomes between the two groups were compared using chi-square and both uni- and multivariate analyses. RESULTS From 2015 to 2019, 109 breasts underwent 2S NSM and 103 breasts underwent 1S NSM. Grade 2 or 3 breast ptosis was more common in the 2S group than in the 1S group (60.5% vs 30.5%; p < 0.01). The median time between devascularization and NSM was 30 days (range, 11-415 days). After devascularization, ischemic events occurred in 25.7% of the breasts. Nipple loss occurred in 7.8% of the 1S group and 0% of the 2S group. Both PR and FI NAC ischemic events were observed in 66.7% of the breasts when NSM took place fewer than 20 days (n = 9) after devascularization versus 15% when NSM took place 20 days or longer afterward (n = 100). Overall, NAC, flap ischemic complications, or both occurred in 35.9% of the 1S group versus 20.2% of the 2S group (p < 0.05). In the multivariate analysis, the odds ratio of ischemic complications in the 2S versus the 1S group was 0.38 (range, 0.19-0.75). CONCLUSIONS Fewer ischemic complications and no nipple loss occurred in 2S NSM. Ischemic events are fewer when the interval between devascularization and NSM is 20 days or longer.

Introduction Timing to start of chemoprophylaxis for venous thromboembolism (VTE) in patients with traumatic brain injury (TBI) remains controversial. We hypothesize that early administration is not associated with increased intracranial hemorrhage. Methods A retrospective study of adult patients with TBI following blunt injury was performed. Patients with penetrating brain injury, any moderate/severe organ injury other than the brain, need for craniotomy/craniectomy, death within 24 hours of admission, or progression of bleed on 6 hour follow-up head computed tomography scan were excluded. Patients were divided into early (≤24 hours) and late (>24 hours) cohorts based on time to initiation of chemoprophylaxis. Progression of bleed was the primary outcome. Results 264 patients were enrolled, 40% of whom were in the early cohort. The average time to VTE prophylaxis initiation was 17 hours and 47 hours in the early and late groups, respectively ( P < .0001). There was no difference in progression of bleed (5.6% vs. 7%, P = .67), craniectomy/-craniotomy rate (1.9% vs. 2.5%, P = .81), or VTE rate (0% vs. 2.5%, P = .1). Conclusion Early chemoprophylaxis is not associated with progression of hemorrhage or need for neurosurgical intervention in patients with TBI and a stable head CT 7 hours following injury.

The recent use of placing a BioZorb device during breast conservation surgery has been shown to improve targeting of adjuvant radiation therapy by significantly reducing target volume to the breast. However, the risks of surgical and/or infectious complications related to a BioZorb placement are largely unknown. In this case report, we describe a patient who underwent BioZorb placement after breast lumpectomy for ductal carcinoma in situ (DCIS), who presented with repeated infections and eventual erosion of the BioZorb through her nipple-areolar complex (NAC), requiring surgical debridement and excision of her NAC and BioZorb 1 year postoperatively.

Background: The rates of incidental appendiceal neoplasms after appendectomy performed for acute appendicitis is

Management of a ruptured hepatocellular adenoma during pregnancy is a rare and potentially life-threatening entity. Few case reports have described management of the pregnant patient who presents in haemorrhagic shock secondary to a ruptured liver adenoma. A 30-year-old primigravid woman at 31 weeks pregnant presented with abdominal pain and fetal bradycardia. After stat caesarean delivery of the infant, she had continued hemoperitoneum and was in shock secondary to an undiagnosed ruptured liver mass. General surgery was consulted intraoperatively and performed an exploratory laparotomy, packing and temporary closure. She was subsequently taken to interventional radiology (IR) for angioembolisation of the left hepatic artery. After stabilisation, she underwent formal abdominal closure. Management of a ruptured hepatocellular adenoma in pregnancy requires urgent multidisciplinary care including obstetrics gynaecology, general surgery and IR.

Screening for blunt cerebrovascular injuries (BCVIs) in asymptomatic high-risk patients has become routine. To date, the length of this asymptomatic period has not been defined. Determining the time to stroke could impact therapy including earlier initiation of antithrombotics in multiply injured patients. The purpose of this study was to determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury.Patients with a BCVI-related stroke from January 2007 to January 2017 from 37 trauma centers were reviewed.During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred.The majority of patients suffer BCVI-related stroke in the first 72 hours after injury. Time to stroke can help inform clinicians about initiation of treatment in the multiply injured patient.Prognostic/Epidemiologic, level III.

Surgical resection with curative intent remains the standard of care for colon cancer. This study aims to compare the 30-day outcomes and oncologic results following open, laparoscopic, and robot-assisted right colon resection for colon cancer using the Targeted Colectomy American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.All patients undergoing elective, right colon resection with primary anastomosis were identified within the targeted colectomy ACS-NSQIP database. Only patients with stage I, II, or III colon cancer were included. The association of surgical approach with oncologic results and 30-day morbidity and mortality outcomes was investigated using a variety of statistical tests.A total of 3518 patients met inclusion criteria; 1024 (29.1%) underwent open surgery (OS), 2405 (63.4%) underwent laparoscopic surgery, and 89 (2.5%) underwent robotic surgery. Patients undergoing OS were significantly more likely to have positive resection margins (P .001). Patients undergoing OS were significantly more likely to experience prolonged intubation (P = .02), deep wound infections (P = .001), wound dehiscence (P = .005), deep venous thrombosis (P = .04), bleeding requiring a blood transfusion (P .001), a prolonged postoperative ileus (P .001), and longer length of hospital stay (P .001), and were more likely to die (P = .02).The laparoscopic approach to colon resection for colon cancer has lower 30-day morbidity compared to OS. The robotic approach is equivalent to the laparoscopic approach, and its utilization may increase in the future.

Sepsis rapid response teams are being incorporated into hospitals around the world. Based on the concept of the medical emergency team, the sepsis rapid response team consists of a specifically trained team of health care providers educated in the early recognition, diagnosis, and treatment of patients at risk of having or who have sepsis. Using hospital-wide initiatives consisting of multidisciplinary education, training, and specific resource utilization, such teams have been found to improve patient outcomes.

Post-operative pancreatic fistulas remain a significant source of morbidity following pancreatic surgery. Few studies have evaluated the effect of neoadjuvant chemotherapy and radiation on this adverse outcome. This study aims to evaluate the effects of neoadjuvant therapy on 30-day morbidity and mortality following pancreaticoduodenectomy. A retrospective analysis was performed utilizing the targeted pancreas module of the National Surgical Quality Improvement Project (NSQIP) from 2014 to 2015 for patients undergoing pancreaticoduodenectomy with pancreaticojejunal reconstruction. A fistula was defined according to the NSQIP definition. Patient demographics, operative variables, and 30-day outcomes were compared between those who received no neoadjuvant therapy, chemoradiation, chemotherapy alone, and radiation alone. Univariate analysis was completed using chi-square, Fisher exact test, Student’s t test, and Mann-Whitney U test where appropriate. Independent predictors of fistula formation were established using multivariable regression. A P value

Pleural space or chest wall infection is a contraindication to surgical stabilization of rib fractures (SSRF) because of the risk of hardware infection. However, the exact degree of risk is uncertain. SSRF is associated with a decreased need for mechanical ventilation and pneumonia. This case report describes a patient with polytrauma and Candida colonization of the mediastinum who successfully underwent SSRF.

Background The incidence and severity of civilian public mass shooting (CPMS) events continue to rise. Understanding the wounding pattern and incidence of potentially preventable death (PPD) after CPMS is key to updating prehospital response strategy. Methods A retrospective study of autopsy reports after CPMS events identified via the Federal Bureau of Investigation CPMS database from December 1999 to December 31, 2017 was performed. Sites of injury, fatal injury, and incidence of PPD were determined independently by a multidisciplinary panel composed of trauma surgery, emergency medicine, critical care paramedicine, and forensic pathology. Results Nineteen events including 213 victims were reviewed. Mean number of gunshot wounds per victim was 4.1. Sixty-four percent of gunshots were to the head and torso. The most common cause of death was brain injury (52%). Only 12% (26 victims) were transported to the hospital and the PPD rate was 15% (32 victims). The most commonly injured organs in those with PPD were the lung (59%) and spinal cord (24%). Only 6% of PPD victims had a gunshot to a vascular structure in an extremity. Conclusions The PPD rate after CPMS is high and is due mostly to non-hemorrhaging chest wounds. Prehospital care strategy should focus on immediate point of wounding care by both laypersons and medical personnel, as well as rapid extrication of victims to definitive medical care.

Introduction To date, there are few reports describing the management of traumatic gynecologic injuries leaving physicians with little guidance. Objective Describe the injury patterns and the preferred management of these injuries. Methods A retrospective cohort study was performed using the National Trauma Data Bank (NTDB) from years 2011 to 2013. Female patients age 16 years and older with internal gynecologic injuries were identified based on diagnosis codes. Demographics, associated diagnoses and procedure codes were compiled for the cohort. Results 313 patients met inclusion criteria. The mechanism of injury was blunt in 236 (75%) patients, penetrating in 68 (21%), and other in 9 (4%). The mean Injury Severity Score was 16.6 ± 14.6. Mean age was 34 ± 21 years old. 226 (74.8%) patients had an ovarian and/or fallopian tube injury, 71 (25.2%) had a uterine injury, 8 (3%) had both, and 8 (3%) had injury to the ovarian or uterine vessels only. Of the 226 patients with ovarian and/or fallopian tube injury, 11(5%) underwent repair and 10 (4%) underwent salpingo-oophorectomy. Of the 71 uterine injuries, 15 (21%) underwent repair and 5 (7%) required a hysterectomy. Conclusions Most traumatic internal gynecologic injuries result from blunt mechanism. Currently, these injuries are largely managed non-operatively. When surgery was performed, ovarian and uterine repair was more common than salpingo-oophorectomy and hysterectomy. Prospective large-scale studies are needed to establish a standard of treatment for the management of gynecologic trauma and to assess both short and long term outcomes and fertility rates.

Bariatric surgery is an effective and durable treatment for obesity. However, the number of patients that progress to bariatric surgery after initial evaluation remains low.The purpose of this study was to identify factors influencing a qualified patient's successful progression to surgery in a U.S. metropolitan area.Academic, university hospital.A single-institution retrospective chart review was performed from 2003 to 2016. Patient demographics and follow-up data were compared between those who did and did not progress to surgery. A follow-up telephone survey was performed for patients who failed to progress. Univariate analyses were performed and statistically significant variables of interest were analyzed using a multivariable logistic regression model.A total of 1102 patients were identified as eligible bariatric surgery candidates. Four hundred ninety-eight (45%) patients progressed to surgery and 604 (55%) did not. Multivariable analysis showed that patients who did not progress were more likely male (odds ratio [OR] 2.2 confidence interval [CI]: 1.2-4.2, P.05), smokers (OR 2.4 CI: 1.1-5.4, P.05), attended more nutrition appointments (OR 2.1 CI: 1.5-2.8, P.0001), attended less total preoperative appointments (OR .41 CI: .31-.55, P.0001), and resided in-state compared with out of state (OR .39 CI: .22-.68, P.05). The top 3 patient self-reported factors influencing nonprogression were fear of complication, financial hardship, and insurance coverage.Multiple patient factors and the self-reported factors of fear of complication and financial hardship influenced progression to bariatric surgery in a U.S. metropolitan population. Bariatric surgeons and centers should consider and address these factors when assessing patients.

There is a paucity of literature describing the association of age with the risk of adverse events following bariatric surgery. The purpose of this study is to investigate the association of age with 30-day morbidity and mortality following laparoscopic bariatric surgery using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. All adult patients undergoing laparoscopic Roux-en-Y gastric bypass (RNGYB) or sleeve gastrectomy (SG) were identified within the MBSAQIP database. Patients were divided into five equal age quintiles. Binary outcomes of interest, including cardiac, pulmonary, wound, septic, clotting, and renal events, in addition to the incidence of related 30-day unplanned reintervention, related 30-day mortality, and a composite morbidity and mortality outcome were compared across the age quintiles and procedures. A total of 266,544 patients met inclusion criteria. Older age was associated with an increased risk of all morbidity outcomes except venous thromboembolism events, 30-day mortality, and the composite morbidity and mortality outcome. Patients who underwent Roux-en-Y gastric bypass had worse outcomes per quintile for almost every outcome of interest when compared to patients who underwent sleeve gastrectomy. Older patients and patients who undergo Roux-en-Y gastric bypass are at an increased risk of perioperative morbidity and mortality following laparoscopic bariatric surgery. Additional studies are needed to determine the association of age with long-term weight loss and cardiometabolic comorbidity resolution following bariatric surgery in order to determine if the increased perioperative risk is offset by improved long-term outcomes in older patients undergoing bariatric surgery.

Design/Methods: Adult patients presenting to the emergency department who had an ultimate discharge diagnosis of ischemic stroke were included in this cohort. The prehospital GCS was obtained from ambulance records in real time, performed by EMS crew. The outcomes of interest were stroke severity as measured by NIHSS, occurrence of endovascular intervention, functional outcome measured by modified Rankin score, and death within 90 days. Logistic regression analyses using JMP 8.0 for the mac performed to assess for correlation. Results: There were upto 4 pre-hospital GCS collected in the cohort (n=145), depending on transportation times. For this study, the first pre-hospital GCS, obtained at the time of first patient contact, was used. GCS Distribution followed a non parametric pattern; the median GCS was 15, range 3-15, IQR 12.5-15. The median and IQRs were: pulse 78 (70-90), sBP 151 (133-176), dBP 83 (72-97), MAP 106 (95-121). Table 1 depicts the number of patients with each GCS, and their median time of arrival to the ED after symptom onset. On univariate analysis, prehospital GCS was significantly correlated with each of the outcome measures of interest. Patients with lower GCS were significantly more likely to have more severe strokes (P Conclusions: The prehospital GCS appears to be a good predictor of stroke severity, and thus correlates for higher likelihood of endovascular intervention. Similarly, the prehospital GCS also correlates well with functional outcome at hospital discharge and death within 90 days. Disclosure: Dr. Weaver has nothing to disclose. Dr. Nappi has nothing to disclose. Dr. Bodhit has nothing to disclose. Dr. Ju has nothing to disclose. Dr. Applewhite has nothing to disclose. Dr. Hedna has nothing to disclose. Dr. Waters has nothing to disclose. Dr. Stead has nothing to disclose.

Objective: To determine whether prehospital vital signs are correlated with outcome after acute intracerebral hemorrhage. Design/Methods: This analysis included all adult patients who presented with an intracerebral hemorrhage during the study period. Patients with subarachnoid and subdural hemorrhages were not included. Prehospital data were obtained from EMS. Prehospital data collected included GCS, pulse, glucose, systolic and diastolic BP, and mean arterial pressure (MAP). Outcomes included stroke severity and Death. Stroke severity was determined by the NIHSS in the Emergency Department. Death after ICH was ascertained from follow up clinic visits, medical records, and the social security death index. Results: 50% of the cohort arrived by EMS. Table 1 depicts the median and interquartile ranges for the prehospital vitals. The median time from symptom onset to presentation was 103 minutes, with an interquartile range of 82 to 171 minutes. The median NIHSS was 16 (IQR 10-26). A total of 64% of the cohort died. Median days to death was 2, with an interquartile range of 1 to 13, and a total range of 0 to 26. Functional outcome as measured by the modified rankin score demonstrated a median of 5. Patients who has a low GCS in the field were significantly more likely to have more severe stroke (p= 0.0152, and have a worse functional outcome (p=0.0027), and higher risk of death (p=.0095). Similarly, patients with lower mean arterial pressure were also significantly more likely to have a higher risk of death (p=.0219). Elevated prehospital glucose was significantly associated with death (p=0.0336). Indeed hyperglycemia was significantly associated with poor outcome (p=0.0158 for NIHSS; and p= 0.0299 for Rankin) for the entire cohort, regardless of whether they came via EMS. Conclusions: Prehospital parameters appear to be correlated with worse outcomes after acute intracerebral hemorrhage. Disclosure: Dr. Bodhit has nothing to disclose. Dr. Ju has nothing to disclose. Dr. Nappi has nothing to disclose. Dr. Weaver has nothing to disclose. Dr. Applewhite has nothing to disclose. Dr. Hedna has nothing to disclose. Dr. Waters has nothing to disclose. Dr. Stead has nothing to disclose.