Ravi S. Radhakrishnan

Esophageal atresia (EA) is a rare congenital anomaly of the foregut. Several anatomic variants have been described, ranging from isolated esophageal discontinuity to forms associated with tracheoesophageal fistula, with some variants occurring far less frequently than others. A premature infant (33 weeks, 1.5 kg) presented with a gasless abdomen and a nasogastric tube coiled at T4. Bronchoscopy revealed a Grade 1 laryngeal cleft without fistula, consistent with type A EA, and a gastrostomy was placed. The initial six-vertebral gap shortened to 2.5 over six weeks. Collis gastroplasty and thoracic anastomosis were performed. Postoperative esophagram revealed a tract to the airway, suggesting a type B EA. Repeat bronchoscopy confirmed the fistula, which was closed via a cervical approach. Recovery and follow-up imaging were uneventful. Type B EA is rare and easily missed. Repeat imaging and bronchoscopy are crucial for accurate diagnosis and management.

Importance: Individuals who are incarcerated represent a vulnerable group due to concerns about their ability to provide voluntary and informed consent, and there are considerable legal protections regarding their participation in medical research. Little is known about the quality of surgical care received by this population.Objective: To evaluate perioperative surgical care provided to patients who are incarcerated within the Texas Department of Criminal Justice (TDCJ) and compare their outcomes with that of the general nonincarcerated population.Design, Setting, and Participants: This cohort study analyzed data from patients who were incarcerated within the TDCJ and underwent general or vascular surgery at the University of Texas Medical Branch (UTMB) from 2012 to 2021. Case-specific outcomes for a subset of these patients and for patients in the general academic medical center population were obtained from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) and compared. Additional quality metrics (mortality index, length of stay index, and excess hospital days) from the Vizient Clinical Data Base were analyzed for patients in the incarcerated and nonincarcerated groups who underwent surgery at UTMB in 2020 and 2021 to provide additional recent data. Patient-specific demographics, including age, sex, and comorbidities were not available for analysis within this data set.Main Outcome and Measures: Perioperative outcomes (30-day morbidity, mortality, and readmission rates) were compared between the incarcerated and nonincarcerated groups using the Fisher exact test.Results: The sample included data from 6675 patients who were incarcerated and underwent general or vascular surgery at UTMB from 2012 to 2021. The ACS-NSQIP included data (2012-2021) for 2304 patients who were incarcerated and 602 patients who were not and showed that outcomes were comparable between the TDCJ population and that of the general population treated at the academic medical center with regard to 30-day readmission (6.60% vs 5.65%) and mortality (0.91% vs 1.16%). However, 30-day morbidity was significantly higher in the TDCJ population (8.25% vs 5.48%, P = .01). The 2020 and 2021 data from the Vizient Clinical Data Base included 629 patients who were incarcerated and 2614 who were not and showed that the incarcerated and nonincarcerated populations did not differ with regard to 30-day readmission (12.52% vs 11.30%) or morbidity (1.91% vs 2.60%). Although the unadjusted mortality rate was significantly lower in the TDCJ population (1.27% vs 2.68%, P = .04), mortality indexes, which account for case mix index, were similar between the 2 populations (1.17 vs 1.12).Conclusions and Relevance: Findings of this cohort study suggest that patients who are incarcerated have equivalent rates of mortality and readmission compared with a general academic medical center population. Future studies that focus on elucidating the potential factors associated with perioperative morbidity and exploring long-term surgical outcomes in the incarcerated population are warranted.

Background: Cholecystoenteric fistulae are rare complications of gallstone disease, with a reported incidence of 0.5% to 0.9% of cholecystectomies. Cholecystoduodenal is the most common fistula followed by cholecystocolonic fistulae.Summary: We report a case of pneumobilia resulting from a combined cholecystoduodenal and cholecystocolonic fistulae treated with a laparoscopic subtotal cholecystectomy and open repair of the enteric fistulae.Conclusion: Combined cholecystoduodenal and cholecystocolonic fistulae are an extremely rare complication of gallstone disease, and meticulous preoperative planning and operative dexterity are needed to safely manage these unusual fistulae.

BACKGROUND: Burn injury induces multiple signaling pathways leading to a significant inflammatory storm that adversely affects multiple organs, including the heart. Poly (ADP-ribose) polymerase inhibitor 1 (PARP1) inhibition, with specific agents such as N-(5,6-Dihydro-6-oxo-2-phenanthridinyl)-2-acetamide (PJ34), is effective in reducing oxidative stress and cytokine expression in the heart. We hypothesized that PARP1 inhibition would reduce inflammatory signaling and protect against burn injury–induced cardiac dysfunction. STUDY DESIGN: Male Sprague-Dawley rats (8 weeks old, 300 to 350 g) were randomly assigned to sham injury (Sham), 60% total body surface area burn (24 hours post burn), or 60% total body surface area burn with intraperitoneal administration of PJ34 (20 mg/kg, 24 hours post burn + PJ34) and sacrificed 24 hours after injury. Cardiac function was determined using Vevo 2100 echocardiography. Genetic expression of 84 specific toll-like receptor–mediated signal transduction and innate immunity genes were examined using microarray to evaluate cardiac tissue. Qiagen GeneGlobe Data Analysis Center was used to analyze expression, and genetic clustering was performed using TreeView V2.0.8 software. Real-time quantitative polymerase chain reaction was used to validate identified differentially expressed genes. RESULTS: Burn injury significantly altered multiple genes in the toll-like receptor signaling, interleukin-17 signaling, tumor necrosis factor signaling, and nuclear factor-κB signaling pathways and led to significant cardiac dysfunction. PARP1 inhibition with PJ34 normalized these signaling pathways to sham levels as well as improved cardiac function to sham levels. CONCLUSIONS: PARP1 inhibition normalizes multiple inflammatory pathways that are altered after burn injury and improves cardiac dysfunction. PARP1 pathway inhibition may provide a novel methodology to normalize multiple burn injury–induced inflammatory pathways in the heart.

In 2016, an estimated 486,000 individuals sustained burn injuries requiring medical attention. Severe burn injuries lead to a persistent, hyperinflammatory response that may last up to 2 years. The persistent release of inflammatory mediators contributes to end-organ dysfunction and changes in genome expression. Burn-induced cardiac dysfunction may lead to heart failure and changes in cardiac remodeling. Cytokines promote the inflammatory cascade and promulgate mechanisms resulting in cardiac dysfunction. Here, we review the mechanisms by which TNFα, IL-1 beta, IL-6, and IL-10 cause cardiac dysfunction in post-burn injuries. We additionally review changes in the cytokine transcriptome caused by inflammation and burn injuries.