Spontaneous Enterocutaneous Fistula

Spontaneous scrotal enterocutaneous fistulas (ECFs) are rare and more common in countries with poor access to medical care. Our patients represent the first two reported adult cases of scrotal ECFs in the United States. Both patients were 83-year-old males who presented from assisted living facilities with past medical histories of prostate cancer. The first patient had an ECF from his cecum to right scrotum and the second patient had an ECF from his sigmoid colon to left scrotum. These are the first recorded cases describing spontaneous scrotal ECFs in adults in the United States. They are also the seventh and eighth reported cases worldwide. Both patients had delayed presentations of their incarcerated hernias because their scrotal ECFs decompressed their incarcerated bowels and attenuated the development of obstructive symptoms. Each patient underwent a successful orchiectomy by urology and bowel resection with ligation of their scrotal ECFs, and herniorrhaphy by general surgery.

The Cholecystocutaneous Fistula: A Rare Manifestation of Neglected Cholecystitis

Introduction: Cholecystocutaneous fistula is a rare complication of acute or chronic cholecystitis, most often seen in the elderly in whom diagnosis is delayed. Management can be difficult due to it's late presentation, patient comorbidities, and poor candidacy for a major surgical intervention. We report the management of a case of cholecystocutaneous fistula in a patient with chronic lymphocytic leukemia who presented in acute sepsis. Case Report: An 89-year-old female presented with several days of abdominal pain, fever, and a right upper quadrant abdominal wall abscess with surrounding cellulitis. A CT demonstrated fistulization of the gallbladder to the anterior abdominal wall. The patient was stabilized in our ICU and external drainage of the abscess and decompression of the gallbladder was performed for source control. Physicians should be aware of the cholecystocutaneous fistula as a late complication of undiagnosed cholecystitis in the elderly patient population as well as the surgical options available for treatment.

The De Garengeot hernia: A case report of an unusual presentation of appendicitis

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DeGarengeot hernia is still defined as a rare entity in the literature.

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There is no uniform consensus on surgical management of this rare entity.

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Surgical management can be tailored on a case-by-case basis.

Introduction

A De Garengeot hernia is defined by a femoral hernia containing the appendix. Acute appendicitis within a femoral hernia is an extremely rare surgical presentation and occurs in only 0.08–0.013% of cases as cited by the literature.

Presentation of case

A 64-year-old female presented to the Emergency Department of our hospital with acute onset of a right-sided groin bulge that occurred earlier that day after doing heavy lifting. Her workup revealed acute appendicitis contained within an incarcerated right femoral hernia. The patient underwent laparoscopic appendectomy with open femoral hernia repair. Intraoperatively, the appendiceal tip was incarcerated within the hernia sac. It was removed through the open inguinal incision after the appendix base was divided laparoscopically. Final pathology showed inflamed acute appendicitis without evidence for neoplasm.

Discussion

Physicians should be aware of the rare entity of an unusual presentation of appendicitis as well as surgical options for treatment. The literature does not conclude upon a gold standard for method of approach.

Conclusion

De Garengeot hernia remains a rare and unusual surgical presentation of femoral hernia, and complication of the case by incarceration leading to acute appendicitis provides a challenging surgical approach which should be individualized to each patient.

Impact of Early Initiation of Enteral Nutrition on Survival During Pediatric Extracorporeal Membrane Oxygenation

INTRODUCTION

Pediatric data related to safety, tolerance, and outcomes of enteral nutrition (EN) for patients requiring extracorporeal membrane oxygenation (ECMO) are lacking. The objectives of this study were to evaluate early nutrition status and timing of EN initiation on survival during pediatric ECMO.

METHODS

A single center institutional review board-approved retrospective chart review was performed on all pediatric patients requiring ECMO from October 2008 through December 2013. Demographics, ECMO variables, laboratory values, vasoactive inotropic score (VIS), and nutrition data on day 5 (d5) were collected. Patients receiving parenteral nutrition (PN) were compared with those receiving any EN on d5. Analyses were conducted to identify factors influencing survival to completion of ECMO and to discharge.

RESULTS

Forty-nine patients aged 53 ± 76 months met inclusion criteria. Kaplan-Meier curves demonstrated greater survival to discharge in patients receiving any EN, compared with only receiving PN (P = .031). EN on d5 of ECMO support (P = .040) and a higher percentage of daily energy intake achieved (P = .013) were protective, whereas a higher VIS was associated with increased mortality (P = .010). Multivariable analysis demonstrated EN was no longer associated with survival to discharge (P = .139), whereas energy intake (P = .021) and VIS (P = .013) remained significant.

CONCLUSIONS

Pediatric patients who received nutrition that was closer to goal energy intake, as well as those who received any EN early during ECMO, had improved survival to hospital discharge.

Effect of median household income on surgical approach and survival in renal cell carcinoma

PURPOSE

We sought to determine whether median household income (MHI) independently predicts surgical approach (partial vs. radical nephrectomy) and survival in patients with renal cell carcinoma.

METHODS

The U.S. Surveillance Epidemiology and End Results Database (1988-2011) was queried to examine kidney cancer cases and linked to the Area Health Resources File. We correlated surgical approach and survival, both overall and cancer-specific, with tumor stage, age, race, sex, and income data.

RESULTS

Of 152,589 patients diagnosed with renal cell carcinoma, 24,221 (16%) patients underwent partial nephrectomy, 102,771 (67%) patients underwent radical nephrectomy, and 25,597 (17%) patients had no surgery. There was no significant difference in stage of presentation between the wealthiest and poorest MHI quartiles, with approximately 35% of patients in each quartile presenting with T1aN0M0 disease and 17% of patients presenting with metastatic disease. Despite this, 18% of patients in the wealthiest quartile underwent partial nephrectomy compared to 14% of patients in the poorest quartile. Although the percentage of patients undergoing partial nephrectomy rose over the timeframe studied in both the wealthiest and poorest quartiles, the rate of rise was highest in the wealthier group. Those in the poorest quartile were 0.10 times more likely to die of all causes (95% CI: 1.09-1.11, P<0.001) and 0.09 times more likely to die of kidney cancer (95% CI: 1.05-1.10, P<0.001) than those in the wealthiest quartile over the timeframe studied.

CONCLUSIONS

Despite presenting with similar stage, patients with lower MHI less commonly undergo partial nephrectomy and are more likely to die of kidney cancer than those in the highest MHIs.