A Case of Severe Lumbar Necrotizing Soft Tissue Infection from an Ileal Pouch Fistula.

BACKGROUND: Necrotizing soft tissue infection (NSTI) is a rapidly progressive infection characterized by tissue necrosis, septic shock, and is associated with a high risk of death. Key aspects of successful treatment include early recognition and emergent surgical source control. Necrotizing soft tissue infection may occur from a range of etiologies but may also occur rarely from gastrointestinal routes. We report a case of severe lumbar NSTI arising from an ileal pouch fistula in a patient with inflammatory bowel disease. We report a case of a 62-year-old male with a history of ulcerative colitis and restorative proctocolectomy who presented with a severe NSTI of the lumbar region. METHODS: Our operative approach focused on debridement of infected necrotic tissue and abscess drainage to achieve source control. We elected to forego a transabdominal approach during the initial operation given that source control but not source elimination was deemed the initial priority. RESULTS: The patient subsequently underwent a diverting ileostomy and pouch salvage. After a prolonged hospital course, the patient recovered well. CONCLUSIONS: Fistulization from the gastrointestinal tract is a rare but potential source of NSTI. It is not necessary to address the fistula during the initial operation but should be done promptly after the patient stabilizes. Prompt surgical debridement of infected soft tissue as source control remains the cornerstone of the index operation.

Evaluation of advanced laparoscopic skills tasks for validity evidence.

BACKGROUND: Since fundamentals of laparoscopic surgery (FLS) represents a minimum proficiency standard for laparoscopic surgery, more advanced proficiency standards are required to address the needs of current surgical training. We wanted to evaluate the acceptance and discriminative ability of a novel set of skills building on the FLS model that could represent a more advanced proficiency standard-advanced laparoscopic surgery (ALS). METHODS: Qualitative and quantitative analyses were employed. Quantitative analysis involved comparison of expert (PGY 5+), intermediate (PGY 3-4) and novice (PGY 1-2) surgeons on FLS and ALS tasks. Composite scores included time and errors. Standard FLS errors were added to task time to create the composite score. Qualitative analysis involved thematic review of open-ended questions provided to experts participating in the study. RESULTS: Out of 48 participants, there were 15 (31 %) attendings, 3 (6 %) fellows and 30 (63 %) residents. By specialty, 54 % were general/MIS/bariatric/colorectal (GMBC) and 46 % were other (urology and gynecology). There was no difference between experience level and performance on FLS and ALS tasks for the entire cohort. However, looking at the GMBC subgroup, experts performed better than novices (p = 0.012) and intermediates performed better than novices (p = 0.057) on ALS tasks. There was no difference for the same group in FLS performance. Also, GMBC subgroup performed significantly better on FLS (p = 0.0035) and ALS (p = 0.0027) than the other subgroup. Thematic analysis revealed that the majority of experts felt that ALS was more realistic, challenging and clinically relevant for specific situations compared to FLS. CONCLUSION: For GMBC surgeons, we were able to show evidence of validity for a series of advanced laparoscopic tasks and their relationship to surgeon skill level. This study may represent the first step in the development of an advanced laparoscopic skills curriculum. Given the high degree of specialization in surgery, different advanced skills curricula will need to be developed for each specialty.