Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Traumatic diaphragm injuries (TDI) pose both diagnostic and therapeutic challenges in both the acute and chronic phases. There are no published practice management guidelines to date for TDI. We aim to formulate a practice management guideline for TDI using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. METHODS: The working group formulated five Patient, Intervention, Comparator, Outcome questions regarding the following topics: (1) diagnostic approach (laparoscopy vs. computed tomography); (2) nonoperative management of penetrating right-sided injuries; (3) surgical approach (abdominal or thoracic) for acute TDI, including (4) the use of laparoscopy; and (5) surgical approach (abdominal or thoracic) for delayed TDI. A systematic review was undertaken and last updated December 2016. RevMan 5 (Cochran Collaboration) and GRADEpro (Grade Working Group) software were used. Recommendations were voted on by working group members. Consensus was obtained for each recommendation. RESULTS: A total of 56 articles were used to formulate the recommendations. Most studies were retrospective case series with variable reporting of outcomes measures and outcomes frequently not stratified to intervention or comparator. The overall quality of the evidence was very low for all Patient, Intervention, Comparator, Outcomes. Therefore, only conditional recommendations could be made. CONCLUSION: Recommendations were made in favor of laparoscopy over computed tomography for diagnosis, nonoperative versus operative approach for right-sided penetrating injuries, abdominal versus thoracic approach for acute TDI, and laparoscopy (with the appropriate skill set and resources) versus open approach for isolated TDI. No recommendation could be made for the preferred operative approach for delayed TDI. Very low-quality evidence precluded any strong recommendations. Further study of the diagnostic and therapeutic approaches to TDI is warranted. LEVEL OF EVIDENCE: Guideline; Systematic review, level IV.

Management of penetrating extraperitoneal rectal injuries: An Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: The management of penetrating rectal trauma invokes a complex decision tree that advocates the principles of proximal diversion (diversion) of the fecal stream, irrigation of stool from the distal rectum, and presacral drainage based on data from World War II and the Vietnam War. This guideline seeks to define the initial operative management principles for nondestructive extraperitoneal rectal injuries. METHODS: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding penetrating rectal trauma from January 1900 to July 2014. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included the management principles of diversion, irrigation of stool from the distal rectum, and presacral drainage using the GRADE methodology. RESULTS: A total of 306 articles were screened leading to a full-text review of 56 articles. Eighteen articles were used to formulate the recommendations of this guideline. CONCLUSION: This guideline consists of three conditional evidence-based recommendations. First, we conditionally recommend proximal diversion for management of these injuries. Second, we conditionally recommend the avoidance of routine presacral drains and distal rectal washout in the management of these injuries.

Timing and type of surgical treatment of Clostridium difficile-associated disease: a practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Clostridium difficile infection is the leading cause of nosocomial diarrhea in the United States; however, few patients will develop fulminant C. difficile-associated disease (CDAD), necessitating an urgent operative intervention. Mortality for patients who require operative intervention is very high, up to 80% in some series. Since there is no consensus in the literature regarding the best operative treatment for this disease, we sought to answer the following:PICO [population, intervention, comparison, and outcome] Question 1: In adult patients with CDAD, does early surgery compared with late surgery, as defined by the need for vasopressors, decrease mortality?PICO Question 2: In adult patients with CDAD, does total abdominal colectomy (TAC) compared with other types of surgical intervention decrease mortality? METHODS: A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the selected questions. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. RESULTS: Reduction in mortality was significantly associated with early surgery, with a risk ratio (RR) of 0.5 (95% confidence interval [CI], 0.35-0.72). The quality of evidence was rated "moderate." Considering only the first procedure performed, mortality seemed to trend higher for TAC, with an RR of 1.11 (95% CI, 0.69-1.80). Considering only the actual procedure performed, the point estimate switched sides, showing a trend toward decreased mortality with TAC (RR, 0.86; 95% CI, 0.56-1.31). The quality of evidence was rated "very low." CONCLUSION: We strongly recommend that adult patients with CDAD undergo early surgery, before the development of shock and need for vasopressors. We conditionally recommend total or subtotal colectomy (vs. partial colectomy or other surgery) when the diagnosis of The Centers for Disease Control and Prevention is known.

Incarcerated retroperitoneal hernia following total extraperitoneal laparoscopic radical nephrectomy.

Small bowel obstruction (SBO) is a common entity encountered in surgical patients. The most common causes of the SBO range from postoperative adhesions to cancer. We present the case of a 55-year-old male who underwent a laparoscopic left radical nephrectomy and presented with an early SBO. An imaging study revealed an obstructive pattern with proximal dilated jejunum with decompressed distal small bowel. The patient underwent an exploratory laparotomy with extensive lysis of adhesions and release/resection of a long segment of incarcerated jejunum from an 8-cm retroperitoneal hernia in the left renal fossa. The patient was discharged home, and at 3-month follow-up no bowel complaints were reported.

Biomechanical and elastographic analysis of mesenchymal stromal cell treated tissue following surgery.

Hernia repair continues to be a problem facing surgeons today, particularly because of the high incidence of reoccurrence. This work presents preliminary data of a pioneering effort to investigate the effect of mesenchymal stromal cells (MSCs) on mechanical property enhancement in full thickness fascial defects. Heparinized MSCs harvested from a rabbit's tibia/iliac crest were applied to two fascial defects on the rabbit's abdominal wall, with two other defects acting as controls (no MSCs added). After an 8 week recovery period, the entire abdominal fascia was harvested for mechanical property testing and elastographic strain analysis. Preliminary results from uniaxial tensile testing indicate a significant increase in the modulus of toughness strain energy, with at least a 50% increase in the MSC treated defects as compared with the control defects. Results from the elastographic strain analysis show excellent correlation in the calibration of the elastography to the uniaxial tensile test, with nearly identical moduli of elasticity. In addition, the elastographs clearly show tissue property heterogeneity at all stages of tensile testing. The MSC treated tissue demonstrates promise of enhanced material properties over that of the nontreated tissue; testing and analysis is ongoing. The elastography provides pixel-level description of tissue property variations providing critical information on wound healing effectiveness that would be impossible with other methods. In the ongoing research, optical elastography, in combination with the traditional tensile test and tissue histology, will be used to characterize localized biomechanical properties directly within the defect area and to locate "crack" initiation and propagation sights as the material is strained to rupture.