Current fistula management.

PURPOSE OF REVIEW: Enterocutaneous fistulas (ECFs) pose a significant impact in the healthcare system, both financially and in resource utilization. Delivery of optimal care is complex and involves intensive wound care, complex nutritional delivery and multidisciplinary care teams for optimization. Recently, there have been pushes to modernize the traditional approach to ECF care to a new paradigm of protocol-based individualized delivery of care. RECENT FINDINGS: There is an increased trend towards pushing enteral nutrition for the management of ECF patients. Adjuncts, including improved fistuloclysis devices, supplements and absorptive aides have challenged the conventional dogma of ECF treatment. There has also been increased focus on surgical prehabilitation and the ability to improve patient outcomes. SUMMARY: ECF care is complex and requires a multidisciplinary approach focused on source control, nutritional optimization with focus on enteral nutrition, wound care and prehabilitation.

Preoperative endoscopic retrograde cholangio-pancreatography (ERCP) is a risk factor for surgical site infections after laparoscopic cholecystectomy.

BACKGROUND: We sought to examine whether preoperative endoscopic retrograde cholangio-pancreatography (ERCP) increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy. METHODS: Patients admitted to an academic hospital from 2010 to 2016, who were older than 18 and had a laparoscopic or a laparoscopic converted to open cholecystectomy for complicated biliary tract disease were included. We compared those who had a preoperative ERCP to those who did not. Our primary endpoint was the rate of SSI. RESULTS: A total of 640 patients were included. Of them, 122 (19.1%) received preoperative ERCP and 518 (80.9%) did not. The former had different preoperative diagnoses compared to non-ERCP patients (choledocholithiasis [35.2%-7.0%], acute cholecystitis [31.2%-76.4%], gallstone pancreatitis [20.5%-16.2%], and cholangitis [13.1%-0.4%], p < 0.001). The rate of SSI was higher in the preoperative ERCP group (11.5%-4.0%, p = 0.005). In a multivariable analysis conversion to open (OR = 2.57, 95% CI = 1.06-6.21, p = 0.037) and preoperative ERCP (OR = 3.12, 95% CI = 1.34-7.22, p = 0.008) were the only independent predictors of SSI. CONCLUSION: Preoperative ERCP is associated with a threefold increase in the risk of SSI after laparoscopic cholecystectomy.

Universal screening for intimate partner and sexual violence in trauma patients-What about the men? An Eastern Association for the Surgery of Trauma Multicenter Trial.

BACKGROUND: A recent Eastern Association for the Surgery of Trauma-supported multicenter trial demonstrated a similar rate of intimate partner and sexual violence (IPSV) between male and female trauma patients, regardless of mechanism. Our objective was to perform a subgroup analysis of our affected male cohort because this remains an understudied group in the trauma literature. METHODS: We conducted a recent Eastern Association for the Surgery of Trauma-supported, cross-sectional, multicenter trial over one year (March 2015 to April 2016) involving four Level I trauma centers throughout the United States. We performed universal screening of adult trauma patients using the validated Hurt, Insult, Threaten, Scream and sexual violence screening surveys. Risk factors for male patients were identified. χ Test compared categorical variables with significance at p values less than 0.05. Parametric data are presented as mean ± standard deviation. RESULTS: A total of 2,034 trauma patients were screened, of which 1,281 (63%) were men. Of this cohort, 119 (9.3%) men screened positive for intimate partner violence, 14.1% for IPSV, and 6.5% for sexual violence. On categorical analysis of the Hurt, Insult, Threaten, Scream screen, the proportion of men that were physically hurt was 4.8% compared to 4.3% for women (p = 0.896). A total of 4.8% of men screened positive for both IPSV. The total proportion of men who presented with any history of intimate partner violence, sexual violence, or both (IPSV) was 15.8%. More men affected by penetrating trauma screened positive for IPSV (p < 0.00001). The IPSV positivity in men was associated with mental illness, substance abuse, and trauma recidivism. CONCLUSION: One of every 20 men that present to trauma centers is a survivor of both IPSV, with one of every six men experiencing some form of violence. Men are at similar risk for physical abuse as women when this intimate partner violence occurs. The IPSV is associated with penetrating trauma in men. Support programs for this population may potentially impact associated mental illness, substance abuse, trauma recidivism, and even societal-level violence. LEVEL OF EVIDENCE: Epidemiological study, level II.

Multi-institutional, prospective, observational study comparing the Gastrografin challenge versus standard treatment in adhesive small bowel obstruction.

INTRODUCTION: Existing trials studying the use of Gastrografin for management of adhesive small bowel obstruction (SBO) are limited by methodological flaws and small sample sizes. We compared institutional protocols with and without Gastrografin (GG), hypothesizing that a SBO management protocol utilizing GG is associated with lesser rates of exploration, shorter length of stay, and fewer complications. METHODS: A multi-institutional, prospective, observational study was performed on patients appropriate for GG with adhesive SBO. Exclusion criteria were internal/external hernia, signs of strangulation, history of abdominal/pelvic malignancy, or exploration within the past 6 weeks. Patients receiving GG were compared to patients receiving standard care without GG. RESULTS: Overall, 316 patients were included (58 ± 18 years; 53% male). There were 173 (55%) patients in the GG group (of whom 118 [75%] successfully passed) and 143 patients in the non-GG group. There were no differences in duration of obstipation (1.6 vs. 1.9 days, p = 0.77) or small bowel feces sign (32.9% vs. 25.0%, p = 0.14). Fewer patients in the GG protocol cohort had mesenteric edema on CT (16.3% vs. 29.9%; p = 0.009). There was a lower rate of bowel resection (6.9% vs. 21.0%, p < 0.001) and exploration rate in the GG group (20.8% vs. 44.1%, p < 0.0001). GG patients had a shorter duration of hospital stay (4 IQR 2-7 vs. 5 days IQR 2-12; p = 0.036) and a similar rate of complications (12.5% vs. 17.9%; p = 0.20). Multivariable analysis revealed that GG was independently associated with successful nonoperative management. CONCLUSION: Patients receiving Gastrografin for adhesive SBO had lower rates of exploration and shorter hospital length of stay compared to patients who did not receive GG. Adequately powered and well-designed randomized trials are required to confirm these findings and establish causality. LEVEL OF EVIDENCE: Therapeutic, level III.

Creation of the first Hartford Consensus compliant elementary school in the USA.

BACKGROUND: The Hartford Consensus established a framework for minimizing deaths due to mass shootings, specifically eliminating preventable deaths due to limb exsanguination. Two major principles defined within this framework are (1) redefining the first responder role and (2) the ubiquitous availability of proper training in application of hemorrhage control techniques, including tourniquets. We hypothesized that this hemorrhage control posture could be fully translated into an elementary school. METHODS: Following institutional review board approval, all teachers at a prekindergarten through 8th grade elementary school underwent short, intensive instruction on their role as a first responder, as well as indications and proper technique for hemorrhage control and tourniquet application for limb exsanguination. All teachers self-reported their confidence in their role as a first responder as well as tourniquet application indications and technique before and after instruction. Following instruction, teachers were evaluated on proper tourniquet application technique on a simulated limb to assess competence. RESULTS: 26 elementary school teachers and 2 administrative staff underwent training. All reported low confidence in their role as a first responder and in tourniquet application indication and technique before training. Following training, all teachers reported high confidence. Testing demonstrated all teachers were competent in the tourniquet application technique. Following training, each classroom was equipped with a purpose-made commercial tourniquet, and a dedicated hemorrhage control bag was placed in the school's central administrative office. CONCLUSIONS: All teachers were successfully trained to act as first responders and in correct hemorrhage control techniques, which was verified by testing. This is the first elementary school to universally adopt a hemorrhage control posture to eliminate preventable deaths from limb exsanguination advocated by the Hartford Consensus.

The clinical significance of isolated loss of lordosis on cervical spine computed tomography in blunt trauma patients: a prospective evaluation of 1,007 patients.

BACKGROUND: A negative computed tomographic (CT) scan may be used to rule out cervical spine (c-spine) injury after trauma. Loss of lordosis (LOL) is frequently found as the only CT abnormality. We investigated whether LOL should preclude c-spine clearance. METHODS: All adult trauma patients with isolated LOL at our Level I trauma center (February 1, 2011 to May 31, 2012) were prospectively evaluated. The primary outcome was clinically significant injury on magnetic resonance imaging (MRI), flexion-extension views, and/or repeat physical examination. RESULTS: Of 3,333 patients (40 ± 17 years, 60% men) with a c-spine CT, 1,007 (30%) had isolated LOL. Among 841 patients with a Glasgow Coma Scale score of 15, no abnormalities were found on MRI, flexion-extension views, and/or repeat examinations, and all collars were removed. Among 166 patients with Glasgow Coma Scale less than 15, 3 (.3%) had minor abnormal MRI findings but no clinically significant injury. CONCLUSION: Isolated LOL on c-spine CT is not associated with a clinically significant injury and should not preclude c-spine clearance.

Using micropower impulse radar technology to screen for pneumothorax: an international bi-institutional study.

BACKGROUND: Pneumothoraces (PTXs) are a common entity in thoracic trauma. Micropower impulse radar (MIR) has been able to detect PTXs in surgical patients. However, this technology has not been tested previously on trauma patients. The purpose of this study was to determine the sensitivity and specificity of MIR to detect clinically significant PTXs. We hypothesized that MIR technology can effectively screen trauma patients for clinically significant PTXs. METHODS: This was a prospective observational study in Level I trauma centers in Boston, Massachusetts, and Bern, Switzerland. All trauma patients undergoing a chest computed tomographic (CT) scan were eligible for the study. Consent was obtained, and readings were performed within 30 minutes before or after the CT scan. The patients had eight lung fields tested (four on each side). The qualitative and quantitative MIR results were blinded and stored on the device. We then compared the results of the MIR to the CT scan and the need for chest tube drainage. We defined PTXs as clinically significant if they required a chest tube. RESULTS: Seventy-five patients were enrolled, with a mean age of 46 ± 16 years. Eighty-four percent were male. The screening test took approximately 1 minute. All but two patients had blunt chest trauma. Six true-positives, 6 false-positives, 63 true-negatives, and 0 false-negatives resulted in an overall sensitivity of 100%. CONCLUSION: MIR is an easy to use handheld technology that effectively screened patients for clinically significant PTXs, with a sensitivity and negative predictive value of 100%. MIR may be used for rapid, repeatable, and ongoing surveillance of trauma patients. LEVEL OF EVIDENCE: Diagnostic study, level III.

Uninsured South Florida vascular surgery patients are less likely to receive optimal medical management than their insured counterparts.

OBJECTIVE: Vascular disease is the most prevalent condition in patients aged >60 years, leading to increasing complications associated with their comorbid conditions. Poor medical compliance could be one reason why the rate of complications may be higher in this patient population, particularly the uninsured. This study was conducted to better assess rates of medication compliance in vascular surgical patients. METHODS: Consecutive patients seen in vascular clinics at a busy tertiary academic center were prospectively studied. Physicians and physician assistants used a standardized questionnaire to collect patient data and evaluated patients for coexisting medical conditions and medication use. Optimal medical therapy was defined according to the 2006 American Heart Association (AHA)/American College of Cardiology (ACC) "Guidelines for Secondary Prevention for Atherosclerotic Vascular Disease." Data were analyzed using multivariate regression. RESULTS: During the 4-month study period, 180 consecutive patients (47% men) were seen in vascular surgery clinics. Most patients (79%) were nonsmokers and only 21% admitted to smoking. Comorbid conditions surveyed included hypertension in 141, diabetes mellitus in 56, coronary artery disease in 24, hypercholesterolemia in 89, and chronic renal failure in 13; of these, 61% were insured and 39% had no insurance. Overall, only 31% of all patients were receiving adequate medical therapy for their comorbid conditions, and about 66% were receiving suboptimal medical treatment for their vascular disease. Uninsured patients were less likely (19%) than insured patients (39%) to receive optimal medical therapy (P = .012). Lack of insurance was a predictor of suboptimal medical therapy for hypertension (odds ratio [OR], 3.13; 95% confidence interval [CI], 1.20-8.16; P = .016), hypercholesterolemia (OR, 5.1; 95% CI, 1.87-13.88; P = .001), peripheral arterial disease (OR, 13.32; 95% CI, 2.84-62.54, P < .001), and any disease overall (OR, 2.43; 95% CI, 1.21-4.88, P = .012). Overall, men and women were equally likely (68%) to receive suboptimal medical therapy; however, women were significantly more likely to be undertreated for coronary artery disease (OR, 0.022; 95% CI, 0.0017-0.293; P < .001). CONCLUSIONS: Compliance with optimal medical therapy for secondary risk factor management amongst our vascular surgery patients is low. Uninsured patients are less likely to receive optimal medical therapy than their insured counterparts. This survey provides sobering statistics regarding medical compliance in our population. This issue deserves further study and may indirectly affect outcomes in minority groups that are disproportionately represented in our uninsured patients.

Spontaneous vaginal drainage of a pelvic abscess: an unusual presentation of perforated appendicitis.

We report a child with the unusual presentation of spontaneous vaginal drainage of a pelvic abscess after nonoperative management of perforated appendicitis. Although drainage through the rectum has been previously described, this is the first report of spontaneous transvaginal drainage of a pelvic abscess from appendicitis in a child.