"Emergency Room Incision and Drainage of Perirectal Abscess is Equivalent to Incision and Drainage in the Operating Room".

BACKGROUND: Current guidelines for management of anorectal abscesses make no recommendations for operative vs bedside incision and drainage (I&D). The purpose of this study was to determine if management in the operating room is necessary to adequately drain anorectal abscesses and prevent short-term complications for patients presenting to the emergency department (ED). METHODS: Patients with perirectal abscesses were identified and divided into two groups based on intervention type: "bedside" or "operative." Demographic, laboratory, and encounter data were obtained from the medical record. Study outcomes included 30-day complications (return to the ED, reintervention, and readmission). Data were analyzed with univariate and multivariate analyses using SPSS (version 28). RESULTS: A total of 113 patients with anorectal abscesses were identified. Sixty-six (58%) underwent bedside I&D and 47 (42%) operative I&D. The overall complication rate was 10%. A total of 9 patients (6 bedside and 3 operative) returned to the ED. Six of these patients required reintervention (5 bedside and 1 operative), and 1 was readmitted. Two patients from the bedside group required a second I&D during their index admission. Pre-procedure SIRS (P = .02) was found to be associated with 30-day complications. Provider specialty and training level were not associated with 30-day complications. DISCUSSION: In this study, for patients presenting to the ED, bedside drainage was found to be an adequate management strategy to achieve complete drainage without a significant increase in the rate of complications when compared to operative drainage.

Patients at elevated risk of major adverse events following endarterectomy for asymptomatic carotid stenosis.

BACKGROUND: Carotid endarterectomy (CEA) as treatment in patients with asymptomatic carotid stenosis is the subject of much debate. METHODS: The National Surgical Quality Improvement Program database from 2005 to 2012 was queried. Patients undergoing CEA for asymptomatic carotid stenosis were identified. Preoperative risk factors and patient demographics were compared using chi-square analysis and logistic regression to determine their relation with stroke and death. RESULTS: During an 8-year period, 24,211 CEAs performed for asymptomatic carotid stenosis were identified. Patients with dependent functional status (12.5%), recent myocardial infarction (6.3%), chronic heart failure (5.0%), hypoalbuminemia (4.8%), angina (4.1%), dialysis dependence (3.4%), steroid dependence (3.4%), chronic obstructive pulmonary disease (3.3%), and American Society of Anesthesiologists > 3 (3.2%) had a clinically significant increase in risk of stroke and death. Patients with none of the above risk factors had a stroke and death rate of 1.08%, which was significantly less than the overall stroke and death rate (P < .001). CONCLUSIONS: A high-risk subset of patients undergoing CEA for asymptomatic carotid stenosis can be identified. If patient selection is optimized and perioperative morbidity and mortality are minimized, CEA will continue to play an important role in stroke prevention for those with significant asymptomatic carotid stenosis.

Lymph node harvest in emergent versus elective colon resections.

Quality measures for prognostication of colon cancer include the removal of 12 or more lymph nodes during colon resection. The purpose of this study was to determine whether emergent surgery is associated with inadequate lymph node harvest. The National Cancer Database (NCDB) was queried for colon cancer patients operated on at Huntington Memorial Hospital, Pasadena, California, from 2005 to 2010. Demographic data, indication for surgery, surgeon, stage, lymph node harvest, tumor location, method of surgery, chemotherapy use, and survival were recorded. Univariate analyses were performed to compare lymph node harvest with the variables listed. Three hundred fifty-three patients underwent colon resection between 2005 and 2010. Two hundred ninety-six patients with Stage I to III disease underwent 253 elective (85%) and 43 emergent (15%) colectomies. There was no statistical difference between rates of adequate lymph node harvest in emergent and elective patient groups (86.0 vs 88.1%, P=0.7). Inferior long-term survival was associated with emergent indication and inferior lymph node harvest. Lymph node harvest adequacy showed a gradual increase over time from 79.5 per cent in 2005 to 95.5 per cent in 2010. Despite a perception that emergent surgery is associated with inadequate lymphadenectomy, 5-year data from Huntington Memorial Hospital participation in NCDB does not suggest inferior lymph node harvests in patients operated on for obstruction or perforation.

Surgical site infection rates in laparoscopic versus open colorectal surgery.

The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to evaluate the incidence of postoperative surgical site infections (SSIs) between laparoscopic (LAP) and open colorectal surgery. The 2008 ACS-NSQIP Participant Use File was queried by Current Procedural Terminology codes for colorectal surgery cases. SSI rates were compared between groups using Pearson chi-square and Fisher exact tests. Univariate and multivariate analyses were performed to identify factors associated with the LAP approach and/or SSIs. A total of 7,755 LAP and 16,184 open cases were identified. The laparoscopic group had an SSI rate of 9.4 versus 15.7 per cent for the open group (P < 0.0001). There was no statistical difference in the type of SSI (superficial, deep, and/or organ space) between the two groups. Although multivariate analysis identified several factors associated with SSIs of different types, LAP was the only factor found to decrease risk, whereas wound class and operative time were found to increase risk among all categories of SSIs. Despite a significantly lower incidence of postoperative SSI, only 32 per cent of colorectal surgery was performed laparoscopically in NSQIP hospitals in 2008. Wider adoption of LAP approaches for colorectal surgery should continue to reduce SSIs.

Small intestinal bacterial overgrowth in patients with lower gastrointestinal symptoms and a history of previous abdominal surgery.

BACKGROUND: The small intestinal bacterial overgrowth (SIBO) breath test has had positive results in 84% of patients with irritable bowel syndrome vs 20% of controls. We hypothesized that SIBO would be more prevalent in patients with symptoms consistent with irritable bowel syndrome who have undergone previous abdominal surgery. OBJECTIVE: To identify causative factors for SIBO. DESIGN: Retrospective review. SETTING: Tertiary colorectal surgery clinic. MAIN OUTCOME MEASURE: Result of SIBO breath test. RESULTS: We identified 77 patients whose differential diagnosis included SIBO from January 1, 2005, to December 31, 2007; 18 were excluded because of noncompliance with testing and 2 because of a decision to treat SIBO without formal testing. Symptoms were chronic abdominal pain in 30 patients (53%), bloating in 25 (44%), constipation in 37 (65%), and diarrhea in 7 (12%). Mean (SD) symptom duration was 45 (22) months. Of the 57 patients enrolled in this study, 45 (79%) tested positive for SIBO and 37 (82%) of those had a history of surgery, whereas 12 (21%) tested negative for SIBO and 9 (75%) of those had a history of surgery. Of the 36 SIBO-positive patients with a history of abdominal surgery (mean number of procedures, 2), the surgery locations were as follows: female reproductive organs, 23 (64%); hindgut, 15 (42%); foregut, 8 (22%); and midgut, 6 (17%). Open surgery alone was performed in 32 patients (56%) vs laparoscopic surgery in 7 (12%). Both open and laparoscopic procedures had been performed in 6 patients (11%). Four patients (7%) had a history of small intestinal obstruction. The mean age of SIBO-positive patients was higher than that of SIBO-negative patients (57 vs 44 years; P < .01). Analysis did not reveal any clinically significant independent factor associated with SIBO. CONCLUSION: Physicians should consider SIBO in the differential diagnosis of patients with normal anatomic findings and chronic lower gastrointestinal complaints.

Clinical outcomes and implications of failed infrainguinal endovascular stents.

OBJECTIVE: While the influence of initial TransAtlantic InterSociety Consensus (TASC) II classification has been clearly shown to influence the primary patency of infrainguinal stenting procedures, its effect on outcomes once stent failure has occurred is less well documented. It is the objective of this paper to determine whether clinical outcomes and implications of anatomic stent failure vary according to initial TASC II classification. METHODS: Results were analyzed by TASC II classification. Kaplan-Meier survival curves were plotted and differences between groups tested by log-rank method. A Cox proportional hazards regression model was used to perform the multivariate analysis. RESULTS: During a 5-year period, 239 angioplasties and stents were performed in 192 patients. Primary patency was lost in 69 stented arteries. Failure was due to one or more hemodynamically significant stenoses in 43 patients, and occlusion in 26 patients. After primary stenting, limbs initially classified as TASC C and D were more likely to fail with occlusion (P < .0001), require open operation (P = .032), or lose run-off vessels (P = .0034) than those classified as TASC A or B. In two patients initially classified as TASC C, stent failure changed the level of open operation to a more distal site. Percutaneous reintervention was performed on 35 limbs. Successful reintervention improved the patency of TASC A and B lesions to 92%, 85%, and 64% and TASC C and D lesions to 78%, 72%, and 50% at 12, 24, and 36 months, respectively. Initial TASC classification was highly predictive of first anatomic failure (P < .0001), but it did not predict the durability of subsequent catheter based reintervention (P = .32). Ten patients with stent failure required operation, and five underwent amputation; all had failed with occlusion. Overall limb salvage was 89% and peri-procedural mortality was 0.4%. CONCLUSIONS: Following primary stenting of the superficial femoral artery (SFA) and popliteal artery, lesions classified as TASC C or D are more likely to fail with occlusion, lose run-off vessels, and alter the site of subsequent open operation than their TASC A and B counterparts. Although these complications are infrequent, they may negatively impact later attempts at revascularization, and this must be considered when deciding upon the proper treatment strategy for patients with infrainguinal occlusive disease.

CT imaging in motorcycle collision victims: routine or selective?

With improving accuracy and efficiency of CT, some trauma centers have used a low threshold for the use of CT scans in the evaluation and assessment of trauma patients. The purpose of this study was to evaluate the diagnostic benefits of liberal CT scanning in multisystem blunt trauma motorcycle accident victims. The trauma registry at our community-based Level II center was accessed to identify consecutive motorcycle accident victims within a 55-month period who: 1) were evaluated on presentation by an attending trauma surgeon; and 2) underwent a head, cervical spine, chest, abdomen, or pelvis CT scan or any combination as part of their initial assessment. For those patients with clinically significant findings identified on CT, the percentage of those with negative clinical examinations was calculated. We found that 48, 77, 47, and 69 per cent of patients with clinically significant findings on head, cervical spine, thoracic, and abdominal CT, respectively, had normal clinical examinations. Our data suggest lower thresholds for CT use in the evaluation of patients sustaining multisystem blunt trauma should be adopted, even in the face of normal clinical examinations. This is especially true for the neck and abdominal regions.

Outcomes of blunt head trauma without intracranial pressure monitoring.

Although guidelines exist for intracranial pressure (ICP)-guided treatment after head trauma, no conclusive data exist that support routine ICP monitoring. A retrospective case series was reviewed of all patients admitted to the intensive care unit with a diagnosis of blunt head trauma between January 1, 1999 and December 31, 2004. None of the patients in the final analysis had ICP monitoring. Data collected included age, sex, mechanism of injury, Glasgow Coma Score (GCS) at admission, injury severity score, disposition, and length of stay. One hundred thirty-one patients with a median age of 41 years were included. There were 104 men (79%). The median GCS at admission was 12. There were 22 deaths (17% mortality). Stepwise logistic regression analysis identified older age, higher injury severity score, and lower GCS to be predictors of death. The mortality rate was higher in patients with GCS < or =8 compared with GCS >8 (33% vs 8%, respectively; P < 0.001). Ten of 23 patients with a GCS of 3 died (43% mortality). The median time to death for patients with a GCS of 3 was 2 days. Although the Brain Trauma Foundation has published guidelines advocating routine ICP monitoring, no large randomized prospective studies are available to determine its effect on outcome. None of the patients in this study had ICP monitoring. Our overall survival rate of 83 per cent is relatively high. Patients with a low GCS and, specifically, those with a GCS of 3 may not benefit from ICP monitoring because of early and irreversible trauma. Variability in the use of ICP monitoring will remain until ICP monitoring can be conclusively proven to improve outcome.

Outcomes of conventional wound treatment in a comprehensive wound center.

Conventional wound care is the elementary treatment modality for treating chronic wounds. However, early treatment with topical growth factors may be needed for a subset of chronic wounds that fail to heal with good wound care alone. A prospective nonrandomized case series from a single-community outpatient wound care clinic is presented here in an effort to identify the subset of chronic wounds that may require early adjuvant intervention. There were 378 consecutive patients with 774 chronic wounds of varying etiology. All patients received 4 weeks of conventional wound care, including weekly debridement and twice-daily dressing changes. Wounds not reduced by 50 per cent volume at 4 weeks were nonrandomly treated with human skin equivalent (Apligraf), platelet-derived wound healing factor, or platelet-derived growth factor isoform BB (becaplermin gel, Regranex). A total of 601 of 774 (78%) wounds healed regardless of treatment type. The median time to heal for all wounds was 49 days (interquartile range = 26-93). More women than men healed (85% vs 71%, respectively, P < 0.0001). Diabetic wounds were as likely to heal as nondiabetic wounds (78% vs 80%, P = 0.5675). Wounds that did not heal had larger volumes and higher grade compared with wounds that healed (P < 0.0001 for both variables). The data presented here show that the majority of chronic wounds will heal with conventional wound care, regardless of etiology. Large wounds with higher grades are less responsive to conventional wound care and will benefit from topical growth factor treatment early in the treatment course.

Peripheral angioplasty with same-day discharge in patients with intermittent claudication.

BACKGROUND: As the number of endovascular interventions increase and resources become scarce, surgeons need to be aware of cost-effective and efficient practice options. Many surgeons routinely admit their patients for overnight observation after uneventful endovascular interventions. Although this may be appropriate for patients with tissue loss and rest pain, we believe that peripheral angioplasty in patients with claudication can be safely performed as an outpatient procedure with significant cost savings. METHODS: All patients with intermittent claudication undergoing peripheral angioplasty by a single vascular surgeon were enrolled prospectively in a same-day discharge protocol. Involved arteries and use of stent and closure device were recorded. Time to mobilization and time to discharge were determined. Patients were observed in an observation unit by a registered nurse, and were examined by the surgeon at the time of ambulation and before discharge. Patients were admitted to the hospital if complications arose during the predetermined observation period. Periprocedural complications and reasons for admission were noted. Patients were evaluated at 1 week, 6 weeks, and 3 to 6 months after the intervention. RESULTS: During 27 months, 112 interventions were performed in 97 patients. The superficial femoral artery was the most frequent site of intervention (47%). Multiple sites had angioplasty in 27 (24%) procedures. Nine (8%) procedures resulted in admission. One patient was admitted for a major puncture site hematoma requiring blood transfusion, two patients for observation of a minor hematoma at the puncture site, one for chest pain, and one for observation of transient bradycardia. The mean time to mobilization was 1.4 +/- 1.3 hours, and the mean time to discharge was 2.8 +/- 1.2 hours. The average postprocedural cost for patients undergoing same-day discharge was $320 per patient, which contrasts with $1800 for routine overnight observation. No deaths or unplanned admissions to the hospital occurred < or =30 days of intervention. CONCLUSIONS: Same-day discharge after peripheral angioplasty is safe and cost-effective. Need for admission is evident within 2 hours. Routine admission after peripheral angioplasty for patients with claudication is unnecessary and should no longer be the standard of care.

Utility of liver function tests after laparoscopic cholecystectomy.

Many surgeons routinely obtain liver function tests (LFTs) after all laparoscopic cholecystectomies. Others argue that LFTs provide no useful information and add time and expense to the patient's hospitalization. This purpose of this study was to determine if routine postoperative LFTs predict complications. One hundred ninety-nine consecutive patients undergoing laparoscopic cholecystectomy were included in the analysis. Nine (4.5%) patients had postoperative complications: eight with retained common bile duct stones and one with a cystic duct stump leak. All were diagnosed with postoperative endoscopic retrograde cholangiopancreatography. Only four of the nine patients had hyperbilirubinemia. Overall, 39 patients had postcholecystectomy hyperbilirubinemia, with four (10%) patients having complications (three retained stones and one had a bile leak). For the entire study population, there was no difference between pre- and postoperative total bilirubin and aspartate aminotransferase levels (0.6 vs 0.6 mg/dL; P = 0.623 and 25 vs 41 U/L; P = 0.111, respectively). There was a statistically significant difference in pre- and postoperative alanine aminotransferase and alkaline phosphatase (31 vs 50 U/L; P = 0.003 and 95 vs 90 U/L; P = 0.001, respectively). Postoperative elevations in liver function tests are frequently seen after laparoscopic cholecystectomy. These elevations do not predict postoperative complications. LFTs should be obtained only when clinically indicated.

Patient sex and success of peripheral percutaneous transluminal arterial angioplasty.

HYPOTHESIS: Female sex negatively affects the durability of percutaneous angioplasty of native arteries supplying the lower extremity. DESIGN: Outcome analysis of the results of percutaneous angioplasty of lower extremity arteries in a single vascular surgery practice. SETTING: University-affiliated community hospital. PATIENTS: All patients undergoing percutaneous intervention on lower extremity arteries during 10 years. INTERVENTIONS: Indication for intervention, anatomic site of intervention, placement of percutaneous stents, and length of lesion undergoing angioplasty were noted. Patient demographics and risk factors were identified. MAIN OUTCOME MEASURES: Results were analyzed by sex. Kaplan-Meier life tables were plotted and differences between groups tested by the log-rank method. A Cox proportional hazards regression model was used to perform the multivariate analysis. RESULTS: During 10 years, 351 angioplasties were performed in 248 patients, 173 in women and 178 in men. There was no difference between men and women in indication for intervention, length and type of lesion treated, or quality of distal runoff. Univariate survival analysis identified a difference in duration of patency between men and women (P = .047). However, multivariate analysis demonstrated no significant difference in duration of patency between men and women (P = .18). Iliac angioplasty and adequate distal runoff were positive predictors of long-term patency (P<.001 for both). CONCLUSIONS: There appears to be no significant difference in the durability of angioplasty between men and women. However, location of angioplasty and adequacy of distal runoff may be useful in determining when to use angioplasty.

De Garengeot hernia: appendicitis within a femoral hernia.

Many surgeons are familiar with Amyand hernia, which is an inguinal hernia sac containing an appendix. However, few surgeons know of the contribution of Rene Jacques Croissant de Garengeot, an 18th century Parisian surgeon, to hernias. He is quoted in the literature as the first to describe the appendix in a femoral hernia sac. We discuss the case of an 81-year-old woman who presented with appendicitis within a femoral hernia, a rare finding at surgery that is almost never diagnosed preoperatively. We also propose crediting Croissant de Garengeot by naming this condition after him. Although his full last name is Croissant de Garengeot, for convenience we suggest the simple diagnosis of "de Garengeot hernia."

Positive intraoperative cholangiography during laparoscopic cholecystectomy: is laparoscopic common bile duct exploration necessary?

The treatment of choledocholithiasis discovered incidentally during laparoscopic cholecystectomy is not yet standardized. Options include laparoscopic common bile duct exploration (LCBDE), postoperative endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy (ERCP-ES), and no intervention. We undertook a review of our case series to determine whether LCBDE is obligatory and which LCBDE method is unsuccessful. During the 6-year study period, 91 patients with choledocholithiasis were identified. Fifty-six patients (62%) underwent LCBDE. Thirteen (23%) of these 56 patients subsequently required ERCP. Balloon sweeping of the common bile duct failed in 10 of 21 patients (48% failure) compared to any other combination of techniques with a failure rate of 1/33 (3%; P < 0.001). Two patients did not undergo complete duct exploration because of technical problems. Thirty-five patients (38%) did not undergo LCBDE. Nine of these patients (26%) did not have ERCP-ES. None of the patients who underwent postoperative ERCP-ES required additional procedures or surgery. LCBDE can successfully treat common bile duct stones, with minimal to no morbidity, but is not mandatory for safely treating choledocholithiasis. Additionally, advanced techniques for clearing the common bile duct are more successful. Surgeons should be proficient at performing these techniques.