Diversion remains the standard of care for modern management of war-related rectal injuries.

INTRODUCTION: Management of rectal injuries in war-injured patients has evolved over time. METHODS: Retrospective review of records of patients sustaining war-related rectal injuries admitted to Walter Reed Army Medical Center from Iraq and Afghanistan. RESULTS: From 2003 to 2011, 67 males ages 18 to 40 sustained rectal injuries after secondary blast (64%), gunshot (33%), motor vehicle crash (1%), or helicopter crash (1%). Injuries were extraperitoneal (72%), intraperitoneal (25%), or both (3%). Rectal abbreviated injury score mean was 3 ± 1. Surgical management included end colostomy (66%), loop colostomy (28%), and no diversion (4%). Distal washout (24%) and drain placement (33%) were performed. Colostomy closure occurred in 79% of patients at an average of 237 days after injury. CONCLUSIONS: Diversion is the preferred treatment of war-related rectal injuries. Loop colostomy is acceptable unless there is potential for evolving rectal injury. Routine use of presacral irrigation and drainage was not supported.

A prediction model for the presence of axillary lymph node involvement in women with invasive breast cancer: a focus on older women.

Axillary lymph node (ALN) status at diagnosis is the most powerful prognostic indicator for patients with breast cancer. Our aim is to examine the contribution of variables that lead to ALN metastases in a large dataset with a high proportion of patients greater than 70 years old. Using the data from two multicenter prospective studies, a retrospective review was performed on 2,812 patients diagnosed with clinically node-negative invasive breast cancer from 1996 to 2005 and who underwent ALN sampling. Univariate and multivariate logistic regression were used to identify variables that were strongly associated with axillary metastases, and an equation was developed to estimate risk of ALN metastases. Of the 2,812 patients with invasive breast cancer, 18% had ALN metastases at diagnosis. Based on univariate analysis, tumor size, lymphovascular invasion (LVI), tumor grade, age at diagnosis, menopausal status, race, tumor location, tumor type, and estrogen and progesterone receptor status were statistically significant. The relationship between age and involvement of axillary metastases was nonlinear. In multivariate analysis, LVI, tumor size and menopausal status were the most significant factors associated with ALN metastases. Age, however, was not a significant contributing factor for axillary metastases. Tumor size, LVI, and menopausal status are strongly associated with ALN metastases. We believe that age may have been a strong factor in previous analyses because there was not an adequate representation of women in older age groups and because of the violation of the assumption of linearity in their multivariate analyses.

Contemporary management of combat-related vertebral artery injuries.

BACKGROUND: Vertebral artery injuries (VAIs) following cervical trauma are uncommon. Advances in imaging technology and emerging endovascular therapies have allowed for the improved diagnosis and treatment of VAIs. We aimed to examine the contemporary management of combat-related penetrating VAIs during current US military operations. METHODS: A retrospective review was performed on US casualties with combat-related VAIs evacuated to a single military institution in the US from September 2001 to 2010 for definitive management. Casualty demographics, mechanism of injury, location and type of VAI, neurologic sequela, associated injuries, method of diagnosis, and therapeutic management were collected. RESULTS: Eleven casualties with a mean age of 26 years (mean [SD] ISS, 18 [7.0]) were found to have VAIs from gunshot wounds (6, 55%) or blast fragments (5, 45%). Cervical spine fractures (8, 72%), facial fractures (5, 45%), and spinal cord injury (3, 27%) were not uncommon. One casualty experienced a posterior cerebellar and parietal infarcts. All injuries were evaluated with digital subtraction angiography, 64-slice multidetector row computed tomography, or both. Casualties were noted to have vertebral artery occlusion (4, 36%), pseudoaneurysms (5, 45%), dissection (1, 9%), or arteriovenous fistula (1, 9%), with most injuries occurring in the V2 segment (6, 55%). Pseudoaneurysms were treated with coiling or stent-assisted coiling. Of 11 casualties, 6 were managed nonoperatively, half of whom with anticoagulation or antiplatelet therapy. CONCLUSION: VAIs are infrequent in modern combat operations, occurring in only 3% of casualties experiencing arterial injuries and are often incidentally discovered during the delayed secondary evaluation of penetrating face and neck injuries at higher echelons of care. One should have a high index of suspicious for a VAI in a casualty with concurrent cervical spine fractures. Endovascular therapies using coils and covered stents have expanded the management options and simplified the treatment of combat-related VAIs. LEVEL OF EVIDENCE: Therapeutic study, level V.

Evolving colon injury management: a review.

The colon is the second most commonly injured intra-abdominal organ in penetrating trauma. Management of traumatic colon injuries has evolved significantly over the past 200 years. Traumatic colon injuries can have a wide spectrum of severity, presentation, and management options. There is strong evidence that most non-destructive colon injuries can be successfully managed with primary repair or primary anastomosis. The management of destructive colon injuries remains controversial with most favoring resection with primary anastomosis and others favor colonic diversion in specific circumstances. The historical management of traumatic colon injuries, common mechanisms of injury, demographics, presentation, assessment, diagnosis, management, and complications of traumatic colon injuries both in civilian and military practice are reviewed. The damage control revolution has added another layer of complexity to management with continued controversy.

Does breast tumor heterogeneity necessitate further immunohistochemical staining on surgical specimens?

BACKGROUND: Prognostic and predictive tumor markers in breast cancer are most commonly performed on core needle biopsies (CNB) of the primary tumor. Because treatment recommendations are influenced by these markers, it is imperative to verify strong concordance between tumor markers on CNB specimens and the corresponding surgical specimens (SS). STUDY DESIGN: A prospective study was performed on 165 women (205 samples) with breast cancer diagnosed from January 2009 to July 2011. Tumor type, grade, estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor 2 (HER2), and Ki67 expression by immunohistochemical (IHC) testing were retrospectively analyzed in the CNB and SS. Contingency tables and agreement modeling were performed. RESULTS: There was substantial agreement between the CNB and SS for PR% and HER2; moderate agreement for tumor type, grade, and ER%; and fair agreement for Ki67%. In 8% of patients (n = 13), tumor heterogeneity was seen. In heterogeneous tumors the overall concordance between the CNB and SS was worse, especially for HER2. Six of these patients had areas of tumor that were positive for HER2, which were not detected in their CNBs. Nine patients had multiple distinct molecular subtypes within their tumor(s). CONCLUSIONS: The heterogeneous distribution of antigens in breast cancer tumors raises concern that the CNB may not adequately represent the true biologic profile in all patients. There is strong concordance for tumor type, ER, and PR between CNB and SS (although a quantitative decline was noted from CNB to SS); however, HER2 activity does not appear to be adequately detected on CNB in patients with heterogeneous tumors. These data suggest that IHC testing on the CNB alone may not be adequate to tailor targeted therapy in all patients.

Management of secondary hemorrhage from early graft failure in military extremity wounds.

BACKGROUND: Secondary hemorrhage after a dehisced vascular reconstruction is a dreaded complication, yet few reports describe the initial management and outcome of casualties with ruptured grafts from military wounds. We aimed to report a single-center experience of graft ruptures after evacuation of casualties to a tertiary hospital in the continental United States. METHODS: Trauma records of US combat casualties were retrospectively reviewed from April 2005 to August 2007. Casualties who underwent an extremity vascular reconstruction in Iraq or Afghanistan and experienced a ruptured graft were included. RESULTS: Ten graft ruptures (mean time, 14 days) occurred during the study period. All casualties were males with penetrating injuries by secondary blast effects (5, 50%) or gunshot wounds (5, 50%). Mean age and Injury Severity Score were 28.2 years (range, 20-41 years) and 21.1 (range 10-32), respectively. Repairs were performed on the superficial femoral (4, 40%), popliteal (2, 20%), brachial (1, 10%), axillary (1, 10%), iliac (1, 10%), and common femoral (1, 10%) arteries using reversed saphenous vein grafts (10, 100%). Initial management included control of hemorrhage and extra-anatomic reconstruction with a vein graft (4), prosthetic graft (4), end-to-end anatomosis (1), or primary amputation (1). Secondary complications in those 10 limbs requiring reintervention included 4 thrombotic graft failures (40%), and 1 transfemoral amputation from a graft infection. Ruptures were frequently associated with long-bone fractures (6, 60%), large soft tissue open wounds (5, 50%) and infection (7, 70%). At a mean follow-up of 37 months, the amputation rate in this series was 30%, with an amputation-free survival of 70%. CONCLUSION: Contaminated military wounds with bony fractures may predispose a graft of any type (vein or prosthetic) to anastomotic dehiscence. Wounds must be carefully debrided, and when grafts cannot be covered with viable muscle, they should be routed around the zone of injury. LEVEL OF EVIDENCE: Therapeutic study, level V.