Background Surgical stabilization of rib fracture (SSRF) is increasingly used for treatment of rib fractures. There are few data on the incidence, risk factors, outcomes, and optimal management strategy for hardware infection in these patients. We aimed to develop and propose a management algorithm to help others treat this potentially morbid complication. Methods We retrospectively searched a prospectively collected rib fracture database for the records of all patients who underwent SSRF from August 2009 through March 2014 at our institution. We then analyzed for the subsequent development of hardware infection among these patients. Standard descriptive analyses were performed. Results Among 122 patients who underwent SSRF, most (73%) were men; the mean (SD) age was 59.5 (16.4) years, and median (interquartile range [IQR]) Injury Severity Score was 17 (13–22). The median number of rib fractures was 7 (5–9), and 48% of patients had flail chest. Mortality at 30 days was 0.8%. Five patients (4.1%) had a hardware infection on mean postoperative day 12.0 (6.6). Median Injury Severity Score (17 [13–42]) and hospital length of stay (9 [6–37] days) in these patients were similar to the values for those without infection (17 [13–22] and 9 [6–12] days, respectively). Patients with infection underwent a median (IQR) of 2 (2–3) additional operations, which included wound débridement (n=5), negative-pressure wound therapy (n=3), and antibiotic beads (n=4). Hardware was removed in 3 patients at 140, 190, and 192 days after index operation. Cultures grew only gram-positive organisms. No patients required reintervention after hardware removal, and all achieved bony union and were taking no narcotics or antibiotics at the latest follow-up. Conclusions Although uncommon, hardware infection after SSRF carries considerable morbidity. With the use of an aggressive multimodal management strategy, however, bony union and favorable long-term outcomes can be achieved. Level of Evidence Therapeutic study, level V.

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There is no significant difference between endoscopic and local operative resections of benign adenomas of ampulla of Vater; recurrences are more common when two or more endoscopic resections are required for complete tumor removal. Appropriate adenomas for endoscopic resection included tumors <3.6 cm that do not extend far enough intraductally (on EUS) to preclude an endoscopic snare ampullectomy.

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Synchronous colon cancer is associated with decreased overall survival compared to patients with solitary tumors. Extended resection does not confer a survival benefit in these patients. Further research is needed to determine how to mitigate the poor outcomes. J. Surg. Oncol. 2016;114:80-85. © 2016 Wiley Periodicals, Inc.

Endovascular repair has become the first line of treatment in most patients with blunt aortic injury. The most common mechanism is deceleration injury affecting the aortic isthmus distal to the origin of the left subclavian artery. Injuries of the distal thoracic aorta are uncommon. We report the case of a 25-year-old male patient who presented with paraplegia and distal thoracic aortic pseudoaneurysm associated with severe thoracolumbar vertebral fracture and displacement after a motocross accident. Endovascular repair was performed using total percutaneous technique and conformable C-TAG thoracic stent-graft (WL Gore, Flagstaff, AZ). Following stent-graft placement and angiographic confirmation of absence of endoleak, thoracolumbar spinal fixation was performed in the same operative procedure. This case illustrates a multispecialty approach to complex aortic and vertebral injury and the high conformability of newer thoracic stent-grafts to adapt to tortuous anatomy.

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Introduction Tube thoracostomy (TT), considered a routine procedure, has significant complications. Current recommendations for placement rely on surface anatomy. There is no information to guide operators regarding angle of insertion relative to chest wall. We aim to determine if angle of insertion is associated with complications of TT. Methods We performed a retrospective review of adult trauma patients who necessitated TT at a level I trauma center over a 2 year period (January 2012 – December 2013). TT performed intraoperatively or using radiological guidance were excluded. Thoracic anteroposterior (AP) or posteroanterior (PA) radiographs were reviewed to determine the angle of insertion of TT relative to the thoracic wall. A previously validated classification method was utilized to categorize complications. Descriptive and univariate statistics were used to compare angle of insertion and complicated vs uncomplicated TT. Results Review identified 154 patients who underwent a total of 246 TT placed for emergent trauma. All patients had a post-procedural chest x-ray. We identified 90 complications (37%) over the study period. 144 of the TT’s reviewed had an angle of insertion less than 45 degrees of which there were 27 complications (19%). 102 of the TT’s had an angle greater than 45 degrees and 63 complications (62%), P<0.0001. Conclusions Tube thoracostomy insertion is inherently dangerous. Placement of TT using a higher angle of insertion greater than 45 degrees is associated with increased complications. Further prospective studies quantifying TT angle of insertion on outcomes are needed. Level of Evidence Level IV therapeutic study.