Minimally invasive approach to low-velocity penetrating extraperitoneal rectal trauma.

Unlike intraperitoneal colorectal injuries, the standard of care for extraperitoneal rectal trauma includes a diverting colostomy due to relative inaccessibility of these injuries for primary repair. New technologies to enhance access to the extraperitoneal rectum have gained increasing use in benign and malignant rectal disease. We present two cases of low-velocity penetrating extraperitoneal rectal trauma. In both cases, a transanal minimally invasive surgery (TAMIS) approach was used to access, and primarily repair, full-thickness rectal lacerations. These patients were successfully managed without a colostomy and without complication. TAMIS enables access to distal rectal injuries, facilitating primary repair and bringing the management of extraperitoneal rectal injuries in line with intraperitoneal injuries, with the potential to avoid fecal diversion.

Complex abdominal wall hernias as a barrier to quality of life in cancer survivors

Background: Many cancer survivors live with postoperative complex abdominal wall hernias (CAWHs). However, the impact of CAWHs on their quality of life is unknown, and few descriptions of patient experiences exist. We performed a qualitative study to explore cancer survivors' experience with CAWHs before and after repair. Methods: Patients waiting to undergo CAWH repair or who had completed the surgery in the previous 18 months were identified from a single surgeon's practice in CAWH at a tertiary care centre. Clinical and demographic data were extracted from the electronic patient record. An in-depth semistructured interview guide was developed by experts in CAWH and qualitative methodology. Interviews were conducted in March 2013. We used comparative analysis techniques and coding strategies to identify themes. Results: Ten preoperative and 12 postoperative participants were interviewed. The average age of the participants was 64 years in both groups, with an even sex distribution. The most frequently diagnosed cancer in both groups was colorectal cancer. Participants' views were organized into 5 themes: 1) unable to return to normal life, 2) sense of abandonment, 3) experiencing fear and distress, 4) preoperative: desperate for help and 5) postoperative: "getting my life back." Conclusion: Our findings show the all-encompassing impact of a CAWH on the life of cancer survivors. They strongly suggest that hernia management should be viewed as an integral part in the continuum of cancer treatment to improve the quality of life of cancer survivors with hernias.

Contexte: De nombreux survivants du cancer vivent avec des hernies postopératoires complexes de la paroi abdominale (HCPA). Or, on ignore quel en est l'impact sur la qualité de vie, et peu de descriptions existent quant à l'expérience des patients. Nous avons procédé à une étude qualitative pour analyser l'expérience des survivants du cancer présentant des HCPA, avant et après une cure de hernie. Méthodes: Les patients attendant une cure d'HCPA ou ayant subi une telle chirurgie dans les 18 mois précédents ont été identifiés à partir de la clientèle d'un seul chirurgien pratiquant la cure d'HCPA dans un centre de soins tertiaires. Des données cliniques et démographiques ont été extraites des dossiers électroniques des patients et un guide d'entrevue semi-structurée a été conçu par des experts de la cure d'HCPA et de méthodologie qualitative. Les entrevues ont été réalisées en mars 2013. Nous avons utilisé des techniques d'analyse comparative et des stratégies de codage pour cerner les thèmes. Résultats: Dix participants ont été interrogés en période préopératoire et 12 en postopératoire. L'âge moyen était de 64 ans dans les 2 groupes et il y avait autant d'hommes que de femmes. Le cancer le plus souvent diagnostiqué dans les 2 groupes était le cancer colorectal. Les perceptions des participants ont été organisées autour de 5 thèmes : 1) incapacité de retourner à la vie normale, 2) sentiment d'abandon, 3) sentiment de peur et de détresse, 4) préopératoire : immense besoin d'aide et 5) postopératoire : « retrouver sa vie ¼ Conclusion: Nos observations font la lumière sur l'impact global de l'HCPA sur la vie des survivants de cancer. Elles suggèrent fortement que la cure de hernie devrait faire partie intégrante du continuum thérapeutique en oncologie pour améliorer la qualité de vie des survivants du cancer porteurs de hernies.

Quality of inguinal hernia operative reports: room for improvement.

BACKGROUND: Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs. METHODS: A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals. RESULTS: We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent repair (8.3%), small bowel viability in incarcerated hernias (10.7%) and occurrence of intraoperative complications (32.5%). Of 18 nonessential elements, deep vein thrombosis prophylaxis, preoperative antibiotics and urgency were reported in 1.9%, 11.7% and 24.3% of ORs, respectively. Repair-specific details were reported in 0 to 97.1% of ORs, including patch sutured to tubercle (55.1%) and location of plug (67.0%). CONCLUSION: Completeness of IHR ORs varied with regards to essential and nonessential items but were generally incomplete, suggesting there is opportunity for improvement, including implementation of a standardized synoptic OR.

CONTEXTE: Les notes opératoires (NO) servent à documenter officiellement les interventions chirurgicales. Elles sont indispensables à des soins optimaux aux patients, à l'imputabilité des médecins, à la facturation de leurs actes, à l'orientation de la recherche clinique et aux vérifications. Les notes narratives non standardisées sont souvent de piètre qualité et incomplètes. Nous avons voulu vérifier l'exhaustivité des notes opératoires narratives concernant les réparations d'hernies inguinales (RHI). MÉTHODES: Une équipe de 4 chirurgiens a créé une liste de vérification standardisée consensuelle comprenant 33 variables applicables à la RHI. Cinq chirurgiens experts des RHI ont classé ces éléments selon qu'ils leurs semblaient essentiels, préférables ou non essentiels. Nous avons passé en revue les NO des RHI ouvertes effectuées dans 6 hôpitaux universitaires. RÉSULTATS: Nous avons passé en revue 213 NO et nous avons exclus les NO concernant 7 hernies fémorales. Les réparations sans tension se sont révélées les plus communes (82,5 %) et la technique plug-and-patch a été la plus fréquente (52,9 %). Les résidents ont dicté 59 % des NO. Sur les 33 variables, 15 étaient considérées essentielles et en moyenne, 10,8 ± 1,3 ont été incluses dans les NO. Parmi les éléments qui laissaient à désirer, mentionnons : première réparation c. réparation récurrente (8,3 %), viabilité du grêle dans les hernies incarcérées (10,7 %) et complications peropératoires (32,5 %). Parmi les 18 éléments jugés non essentiels, la prophylaxie contre la thrombose veineuse profonde, l'antibioprophylaxie et le degré d'urgence ont été mentionnés dans 1,9 %, 11,7 % et 24,3 % des NO, respectivement. Les détails spécifiques à la réparation ont été notés dans 0 à 97,1 % des NO, y compris la fixation de la prothèse au tubercule par des sutures (55,1 %) et la localisation du bouchon (67,0 %). CONCLUSION: L'exhaustivité des NO consignées dans les cas de RHI a varié en ce qui a trait aux éléments jugés essentiels et non essentiels et les NO se sont généralement révélées incomplètes. On en conclut qu'il y a place à amélioration, entre autre par l'adoption d'un modèle synoptique standardisé de NO.

Soluble CD200 is critical to engraft chronic lymphocytic leukemia cells in immunocompromised mice.

CD200 is a transmembrane molecule with an important immunoregulatory role that is overexpressed on most chronic lymphocytic leukemia (CLL) cells. In this study, we characterized a previously unknown soluble form of this molecule in human plasma termed sCD200. Levels of sCD200 were elevated in the plasma of patients with CLL as compared with healthy controls, and there was a significant correlation with CLL disease stage. Infusion of sCD200(hi) CLL plasma into severely immunocompromised NOD.SCIDγ(c)(null) (NSG) mice enhanced the engraftment of CLL splenocytes as compared with mice receiving sCD200(lo) normal plasma. CLL cells were detected in both the spleen and peritoneal cavity of animals for up to 75 days. Engraftment of CLL cells did not occur after infusion of CLL plasma depleted of sCD200 and was abolished in mice treated with anti-CD200 or OKT3 monoclonal antibody (mAb), suggesting a role for both sCD200 and T cells in CLL engraftment. Notably, anti-CD200 mAb was as effective as rituximab in eliminating engrafted CLL cells when administered 21 days after engraftment. Taken together, our findings point to sCD200 as a novel prognostic marker and therapeutic target for CLL. Furthermore, the humanized mouse model described here may prove valuable to preclinically assess new treatment regimens for CLL.

The impact of an acute care emergency surgical service on timely surgical decision-making and emergency department overcrowding.

BACKGROUND: This study evaluated how implementation of an acute care emergency surgery service (ACCESS) affected key determinants of emergency department (ED) length of stay, and particularly, surgical decision time. Also, we analyzed how ACCESS affected ED overcrowding. STUDY DESIGN: We conducted a before and after study of all ED patients referred to ACCESS from January 1, 2007 to June 30, 2009. ACCESS was implemented on July 1, 2008. The primary outcome was surgical decision time; the secondary outcome was a measure of overall ED overcrowding: "time-to-stretcher" for all ED patients. The control groups were patients referred to internal medicine or urology. Patients with appendicitis were studied in order to analyze the impact on patient outcomes and to determine barriers to efficient ED patient flow. RESULTS: Of 2,510 patients, 1,448 patients were pre-ACCESS, and 1,062 were after ACCESS implementation. Implementation of ACCESS was associated with a 15% reduction in surgical decision time (12.6 hours vs 10.8 hours, p < 0.01). During the same period, there were no significant changes in decision time for our control groups. Also, the mean time-to-stretcher for all ED patients decreased by 20%. In patients with appendicitis, we found that patient flow could be further improved by a timely request for surgical consultation and expedited imaging. Finally, we found that patients with nonperforated appendicitis with a fecalith on CT imaging were more likely to suffer perforation while waiting for surgery. CONCLUSIONS: ACCESS reduced surgical decision time for surgical patients. Also, ACCESS improved overall ED crowding, as measured by time-to-stretcher for ED patients. Further improvements could be made by improving time to imaging. Patients referred for nonperforated appendicitis with a fecalith on CT should have expedited surgery.

Advanced trauma life support, 8th edition, the evidence for change.

The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.

Evaluation of bowel and mesenteric blunt trauma with multidetector CT.

Bowel and mesenteric injuries are detected in 5% of blunt abdominal trauma patients at laparotomy. Computed tomography (CT) has been shown to be accurate for the diagnosis of bowel and mesenteric injuries and is the diagnostic test of choice in the evaluation of blunt abdominal trauma in hemodynamically stable patients. Specific CT findings of bowel and mesenteric injuries include bowel wall defect, intraperitoneal and mesenteric air, intraperitoneal extraluminal contrast material, extravasation of contrast material from mesenteric vessels, and evidence of bowel infarct. Specific signs of mesenteric injury are vascular beading and abrupt termination of mesenteric vessels. Less specific signs of bowel and mesenteric injuries include focal bowel wall thickening, mesenteric fat stranding with focal fluid and hematoma, and intraperitoneal or retroperitoneal fluid. When only nonspecific signs of bowel and mesenteric injuries are seen on CT images, correlation of CT features with clinical findings is necessary. A repeat CT examination after 6-8 hours if the patient's condition is stable may help determine the significance of these nonspecific findings.

Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival?

BACKGROUND: Low Glasgow Coma Scale score (GCS) and pupillary status predict poor outcomes in head injury (HI) patients. We compared the mortality of GCS 3 patients having bilateral fixed and dilated pupils (BFDP) with GCS 3 patients having reactive pupils (RP). We then determined if trauma system or patient factors were responsible for the difference in mortality. METHODS: We reviewed all adult, blunt HI patients with GCS=3, admitted to our institution from January 1, 2001 to December 31, 2003. Demographics, injury data, prehospital times, procedures, and outcomes were recorded. RESULTS: During this period, 245 patients were admitted with GCS of 3, and met inclusion criteria. In all, 173 patients were analyzed, after excluding 23 patients who were dead-on-arrival, and 45 others, who were intoxicated with alcohol, or received paralytic agents in the trauma room. All BFDP patients died, whereas 42.0% of reactive pupil (RP) patients died (p < 0.0001). With regards to patient factors, BFDP patients were more likely to be unstable, have extra-axial bleeding, and evidence of midline shift and/or herniation. Trauma system factors, however, may also have had an impact on outcome. Despite having more extra-axial bleeding, BFDP patients were less likely to have a neurosurgical operation than RP patients. CONCLUSION: Patients with GCS of 3 and BFDP have a dismal prognosis. These patients have suffered devastating brain injuries and tend to be hemodynamically unstable. Clinicians, however, are less likely to aggressively treat BFDP patients than RP patients. Further prospective studies are required to determine which patients with GCS of 3 and BFDP are likely to benefit from aggressive treatment.

The immunomodulatory effects of hypertonic saline resuscitation in patients sustaining traumatic hemorrhagic shock: a randomized, controlled, double-blinded trial.

OBJECTIVE: To investigate the potential immunologic and anti-inflammatory effects of hypertonic saline plus dextran (HSD) in hemorrhagic trauma patients. BACKGROUND: Unbalanced inflammation triggered by shock has been linked to multiorgan dysfunction (MOD) and death. In animal and cellular models, HSD alters the inflammatory response to shock, attenuating MOD and improving outcome. It remains untested whether HSD has similar effects in humans. METHODS: A single 250-mL dose of either HSD (7.5% NaCl, 6% dextran-70) or placebo (0.9% NaCl) was administered to adult blunt trauma patients in hemorrhagic shock. The primary outcome was to measure changes in immune/inflammatory markers, including neutrophil activation, monocyte subset redistribution, cytokine production, and neuroendocrine changes. Patient demographics, fluid requirements, organ dysfunction, infection, and death were recorded. RESULTS: A total of 27 patients were enrolled (13 HSD) with no significant differences in clinical measurements. Hyperosmolarity was modest and transient, whereas the immunologic/anti-inflammatory effects persisted for 24 hours. HSD blunted neutrophil activation by abolishing shock-induced CD11b up-regulation and causing CD62L shedding. HSD altered the shock-induced monocyte redistribution pattern by reducing the drop in "classic" CD14 and the expansion of the "pro-inflammatory" CD14CD16 subsets. In parallel, HSD significantly reduced pro-inflammatory tumor necrosis factor (TNF)-alpha production while increasing anti-inflammatory IL-1ra and IL-10. HSD prevented shock-induced norepinephrine surge with no effect on adrenal steroids. CONCLUSIONS: This first human trial evaluating the immunologic/anti-inflammatory effects of hypertonic resuscitation in trauma patients demonstrates that HSD promotes a more balanced inflammatory response to hemorrhagic shock, raising the possibility that similar to experimental models, HSD might also attenuate post-trauma MOD.

Risk and benefit of intravenous contrast in trauma patients with an elevated serum creatinine.

OBJECTIVE: Assess if the benefits outweigh the risks of intravenous (iv) contrast in trauma patients who present with an elevated serum creatinine (Cr). BACKGROUND: Radiologic investigations with iv contrast are often used in trauma patients to rapidly assess for life threatening injuries. However, contrast nephropathy (CNP) is associated with increased morbidity and mortality. This poses a dilemma for the physician who must weigh the risks and benefits of proceeding with iv contrast versus the risks of missed injuries/delayed diagnosis. METHODS: A 2 year (2002-2003) retrospective chart review of all trauma patients presenting with an elevated Cr(> or =1.3 mg/dL or > or =115 micromol/L). Results are mean +/- sd (p < 0.05 significant). RESULTS: Ninety-five patients (age 51 +/- 23 years; ISS 31.7 +/- 15.6; hospital stay 29 +/- 32 days; mortality 9%) presented with a Cr > or = 1.3 mg/dL (31 with Cr > or =1.7; 3 dialysis dependent). Fifty-six (59%) were given iv contrast (C+), of which only 2 (3%) had a transient rise of 25% in Cr within 48 hours versus 6 (16%) patients not exposed to contrast (C-). No C+ patient developed CNP requiring longterm dialysis. Of the 56 undergoing C+ tests, 16 had injuries requiring urgent intervention identified; 16 had injuries that were managed nonoperatively, and 24 had serious injuries ruled out. Of the 39 C- patients, 9 had indeterminate CT's; 2 had missed injuries; and 2 had no intraabdominal injuries found at celiotomy. CONCLUSION: This study suggests the benefits may outweight the risks for proceeding prn with iv contrast in trauma patients with an elevated creatinine. A larger study is needed to confirm these findings.

Assessment of critical appraisal skills.

BACKGROUND: Studies have provided little evidence that critical appraisal skills improve with focused courses. However, outcome measures in these studies have been questionable. The goal of this study was to develop a feasible, reliable, and valid assessment of critical appraisal skills. METHODS: Forty-four surgery residents read three articles and then responded to short answer questions and provided 7-point ratings regarding various methodological aspects of each article. Reliability and validity of the examination were assessed. RESULTS: The mean score was 52.4% (SD 8.6%). Internal consistency of the 55-question examination was 0.77. Interrater reliability of clinician markers was 0.91. Mean score for residents with more intensive critical appraisal training was significantly higher than for those with little or no training (56.6% versus 49.3%, t(35) = 2.31, P = 0.02), suggesting construct validity. CONCLUSIONS: This examination has promising psychometric properties, and may be useful in evaluating critical appraisal curricula.