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Skin grafting for the treatment of enterocutaneous fistulas
e188
Scientific Poster Presentations: 2014 Clinical Congress
METHODS: A comparative study between G-PPG, a commercially available transmission-PPG and laser Doppler was performed utilising an accepted tourniquet compression (TC) model of CS in the anterior compartment of the forearm of healthy adult volunteers. Ethical approval was obtained. RESULTS: In all participants (n¼23), significant changes in blood flow were detected by all three sensors in established (TC pressure 30-60mmHg) and severe (TC pressure >systolic BP) CS models. Only G-PPG detected a significant reduction in blood flow (p<0.001) during early CS modelling (TC pressure <20mmHg). CONCLUSIONS: Green light reflectance PPG could allow for earlier surgical intervention in those at risk of CS, especially children, unconscious or polytrauma patients, potentially reducing morbidity. This inexpensive and non-invasive sensor may also have other roles in detecting cardiovascular deterioration preceding the onset of hypotension, such as early shock in septicaemia. Additional work in these settings and CS are required. Necessity of repeat head computed tomography (CT) scans in mild traumatic brain injury patients Kaveh N Najafi, DO, Geoff Darby, Jacqueline K Pham, BS, Ali Qaderi, Cristobal Barrios Jr, MD, FACS University of California-Irvine, Irvine, CA INTRODUCTION: Traumatic brain injuries (TBI) are a leading cause of mortality and morbidity. The Glasgow Coma Scale (GCS) is a clinical TBI severity grading system. CT scanning has also become a sensitive diagnostic tool in assessing TBIs. Currently, there is a widely varied practice in evaluation of patients with mild TBIs. We hypothesize that patients with an initially positive head CT and stable GCS (15) are less likely to have positive repeat CTs than patients who’s GCS has dropped below 15. METHODS: A 5 year retrospective analysis was done (Jan 2007Dec 2011). Data points included ISS, ICU LOS, Hospital LOS, initial GCS, first head CT scan, lowest GCS between scans, and treatment after 2nd CT. Positive CT findings were considered an increase in contusion, bleed, edema, midline shift, or a new bleed. RESULTS: In 369 patients, those with a stable GCS (15) were less likely to have a positive repeat CT scan than patients who whose GCS dropped (12.9% vs 24.9%, p<.01). They also tended to require less Interventions (0.8% vs 4.0%, p¼0.09). Unchanged patients were more likely to have a lower ISS (14 vs 17, p<.01), ICU LOS(2 vs 3 days, p<.01), and Hospital LOS( 4 vs 6, p<.01). CONCLUSIONS: CT scans are a rapid, non-invasive diagnostic tool that can accurately diagnose a patient’s intracranial status. Our study shows that most patients who have initially positive CT scans and maintain a stable GCS of 15 can still safely forego the cost and radiation exposure of repeated scans.
J Am Coll Surg
Deep organ space infection after emergency bowel resection and anastomosis Stefano Siboni, MD, Elizabeth R Benjamin, MD, PhD, Lydia Lam, MD, FACS, Kenji Inaba, MD, FACS, Konstantinos Chouliaras, MD, Demetrios Demetriades, MD, PhD, FACS Los Angeles County and University of Southern California Medical Center, Los Angeles, CA INTRODUCTION: Deep organ space infection (DOSI) is a serious complication after emergency bowel resection and anastomosis. The aim of this study was to identify the incidence and risk factors for the development of DOSI. METHODS: American College of Surgeons National Surgical Quality Improvement Program database (2005-2010) study including patients who underwent large bowel (LB) and small bowel (SB) resection and primary anastomosis. The incidence, outcomes, and risk factors for DOSI were evaluated using univariate and multivariate analysis. RESULTS: Of the 96,199 patients identified, 17,055 underwent emergency operations. The overall rate of DOSI in emergency operations was 5.8%. On multivariate analysis, emergency operation was not an independent predictor of DOSI. Predictors of DOSI in emergency operations included age, recent weight loss, steroids, wound and advanced ASA classification. Diabetes was not a predictor of DOSI. In emergency cases, location of resection and anastomosis was not predictive of DOSI. CONCLUSIONS: DOSI are common, occurring in 5.8% of patients after emergency bowel resection andanastomosis. Emergency operation is not a predictor of DOSI. Independent predictors of DOSI include wound and ASA classification, recent weight loss, and steroid use. In emergency operations, the location of resection and anastomosis is not a predictor of DOSI. Skin grafting for the treatment of enterocutaneous fistulas Jessica Korsh, Kristen Aliano, MD, Thomas Davenport, MD, FACS Long Island Plastic Surgical Group, Garden City, NY INTRODUCTION: Postoperative enterocutaneous fistulas occur as a complication in 0.8-2% of abdominal surgeries. The majority of enterocutaneous fistulas are treated by pouching, and in spite of numerous technological advancements, fistula treatment options are fairly limited. Additional enterocutaneous fistula treatments include biologic fibrin glue injections, somatostatin analogs (octreotide), and negative pressure wound therapy (NPWT). The mortality rate ranges from 5-37%. Although skin grafting is employed to treat abdominal wounds, there is minimal literature reviewing the use of skin grafting to treat enterocutaneous fistulas. In this paper, we review our experience with the use of acellular dermal matrices and skin grafting in the treatment of enterocutaneous fistulas.
Vol. 219, No. 4S, October 2014
METHODS: A review of three patient cases who underwent treatment of an enterocutaneous fistula with acellular dermal matrices and skin grafting was performed. RESULTS: All three patients healed well with no recurrence. CONCLUSIONS: Our results support the use of skin grafting and fibrin glue as a successful method of treating enterocutaneous fistulas. VAC use has reduced but not eliminated the need for split-thickness skin grafts or mesh. The use of a dermal matrix and fibrin glue prevents contamination from the enteric fluid from the fistula. Additionally this method prevents the bowel from desiccation and touching surrounding dressings. Our results indicate that the acellular dermal matrix is able to be incorporated into the wound and the fibrin glue secures it and closes the fistula. Laparoscopic splenctomy in isolated blunt traumatic splenic injury Asem S Ghasoup, MBChB, FACS, Turki A Al Qurashi, MD, Omar G Sadieh, MBChB, FACS Saad Specialist Hospital, Al-Khobar, Saudi Arabia and Security Force Hospital, Makkah, Saudi Arabia INTRODUCTION: Minor splenic injuries from blunt trauma can be treated conservatively, whereas high-grade injuries require surgical treatment. Although splenectomy is nowadays performed laparoscopically for the treatment of hematological pathologies, in an emergency is performed through conventional laparotomy, progress in surgical skill and new developments in equipment allow us to manage patients with severe splenic blunt trauma laparoscopically. METHODS: The study included 11 patients with isolated blunt TSI. All patients underwent full history taking, complete physical examination, abdomenial CT for splenic injury grading. Surgical interference was indicated when there was deterioration of patient’s hemodynamic parameters. All splenectomies were performed using 3-trocar approch, intraoperative and postoperative (PO) data were collected. RESULTS: CT examination defined 2 patients of grade V, 5 patients of grade IV, and 4 patients of grade III. All patients passed uneventful intraoperative course without conversion to open splenectomy with a mean operative time of 6020.7 minutes and mean amount of total blood loss of 280.6140.1 ml. All patients required blood transfusion with mean number of blood units of 3.41.1; range: 3-5 units.nine patients passed uneventful postoperative course, one patients developed wound infection and one patient developed chest infection that responded to medical treatment. Mean duration of hospital stay for was 5.72 days. All patients completed their follow-up for a mean duration of 14.14.7 months. No follow-up complications were recorded during follow-up period. CONCLUSIONS: LS is a feasible, safe and effective therapeutic modality for cases of blunt TSI providing short recovery times and hospital stay without extensive morbidities or mortalities.
Scientific Poster Presentations: 2014 Clinical Congress
e189
Lodox statscanner: time is money Julie A Dunn, MD, FACS, Hannah Warren, MD, MPH, Beth Jackson, MD, Gavin I Misner, MD, John Kalbfleisch, PhD East Tennessee State University, Johnson City, TN and University of Colorado Health, Fort Collins, CO INTRODUCTION: In 2006 our Level I trauma center installed a Lodox Statscanner TM allowing total skeletal survey in 13 seconds at 1/20th the radiation dose of a chest x-ray. Despite universal use, drop in the number of additional conventional images was less than expected. We delineate reasons for repetitive imaging and assess diagnostic accuracy of anatomical locations. METHODS: A retrospective chart review of 100 random adult blunt trauma patients was undertaken. Trauma to the skeleton was categorized as: Pelvis, upper extremity, and lower extremity by anatomic site: humerus, radius, ulna, elbow, shoulder, wrist/ hand, femur, tibia, fibula, knee, ankle/foot. Conventional and Lodox images were compared to evaluate accuracy. The role of improper positioning was also evaluated. RESULTS: No repeat images were required of chest or pelvis. Injuries frequently missed with Lodox were: hand (88%), foot (40%), primarily metacarpals, metatarsals, and phalanges. Most frequent additional imaging involved the wrist, hand, tibia, fibula, ankle and foot. Injuries to the humerus, radius, ulna, femur, tibia, and fibula were identified in over 80% of cases. Improper positioning occurred in 74% of upper extremities and 26% of lower extremities. Injury-associated limitations caused 62% of improper positioning for lower extremities. CONCLUSIONS: Lodox provides rapid and accurate characterization of long bone injuries. Despite limitations, Lodox allowed early identification of long bones injuries, allowing more rapid orthopedic activation and decreased time to intervention. With added attention to proper positioning, Lodox accuracy can be enhanced, decreasing the need for additional images, saving time, money, and reducing radiation exposure. Distinct patterns of mortality among the injured elderly: an opportunity for improvement of the processes of care Monica Polcz, BS, Fahim A Habib, MBBS, MPH, FACS, Carolina Orbay, BS, Ivan Puente, MD, FACS, Marko Bukur, MD, FACS, Carlos Prays, BS, Rebecca Wiesenfeld, Joe Catino, MD, FACS, Robyn Farrington-Avila, RN, BSN, MBA-HCM, Jaime A Rodriguez, MD, FACS Broward Health Medical Center, Fort Lauderdale, FL and Florida International University, Miami, FL INTRODUCTION: The geriatric population continues to remain a swiftly mounting demographic in trauma, with mortality rates almost twice that of their younger counterparts. The temporal profile of elderly trauma deaths as it relates to opportunities for interventions and program development has not been clearly described. We hypothesized that the elderly would have a distinct mortality
Scientific Poster Presentations: 2014 Clinical Congress
METHODS: A comparative study between G-PPG, a commercially available transmission-PPG and laser Doppler was performed utilising an accepted tourniquet compression (TC) model of CS in the anterior compartment of the forearm of healthy adult volunteers. Ethical approval was obtained. RESULTS: In all participants (n¼23), significant changes in blood flow were detected by all three sensors in established (TC pressure 30-60mmHg) and severe (TC pressure >systolic BP) CS models. Only G-PPG detected a significant reduction in blood flow (p<0.001) during early CS modelling (TC pressure <20mmHg). CONCLUSIONS: Green light reflectance PPG could allow for earlier surgical intervention in those at risk of CS, especially children, unconscious or polytrauma patients, potentially reducing morbidity. This inexpensive and non-invasive sensor may also have other roles in detecting cardiovascular deterioration preceding the onset of hypotension, such as early shock in septicaemia. Additional work in these settings and CS are required. Necessity of repeat head computed tomography (CT) scans in mild traumatic brain injury patients Kaveh N Najafi, DO, Geoff Darby, Jacqueline K Pham, BS, Ali Qaderi, Cristobal Barrios Jr, MD, FACS University of California-Irvine, Irvine, CA INTRODUCTION: Traumatic brain injuries (TBI) are a leading cause of mortality and morbidity. The Glasgow Coma Scale (GCS) is a clinical TBI severity grading system. CT scanning has also become a sensitive diagnostic tool in assessing TBIs. Currently, there is a widely varied practice in evaluation of patients with mild TBIs. We hypothesize that patients with an initially positive head CT and stable GCS (15) are less likely to have positive repeat CTs than patients who’s GCS has dropped below 15. METHODS: A 5 year retrospective analysis was done (Jan 2007Dec 2011). Data points included ISS, ICU LOS, Hospital LOS, initial GCS, first head CT scan, lowest GCS between scans, and treatment after 2nd CT. Positive CT findings were considered an increase in contusion, bleed, edema, midline shift, or a new bleed. RESULTS: In 369 patients, those with a stable GCS (15) were less likely to have a positive repeat CT scan than patients who whose GCS dropped (12.9% vs 24.9%, p<.01). They also tended to require less Interventions (0.8% vs 4.0%, p¼0.09). Unchanged patients were more likely to have a lower ISS (14 vs 17, p<.01), ICU LOS(2 vs 3 days, p<.01), and Hospital LOS( 4 vs 6, p<.01). CONCLUSIONS: CT scans are a rapid, non-invasive diagnostic tool that can accurately diagnose a patient’s intracranial status. Our study shows that most patients who have initially positive CT scans and maintain a stable GCS of 15 can still safely forego the cost and radiation exposure of repeated scans.
J Am Coll Surg
Deep organ space infection after emergency bowel resection and anastomosis Stefano Siboni, MD, Elizabeth R Benjamin, MD, PhD, Lydia Lam, MD, FACS, Kenji Inaba, MD, FACS, Konstantinos Chouliaras, MD, Demetrios Demetriades, MD, PhD, FACS Los Angeles County and University of Southern California Medical Center, Los Angeles, CA INTRODUCTION: Deep organ space infection (DOSI) is a serious complication after emergency bowel resection and anastomosis. The aim of this study was to identify the incidence and risk factors for the development of DOSI. METHODS: American College of Surgeons National Surgical Quality Improvement Program database (2005-2010) study including patients who underwent large bowel (LB) and small bowel (SB) resection and primary anastomosis. The incidence, outcomes, and risk factors for DOSI were evaluated using univariate and multivariate analysis. RESULTS: Of the 96,199 patients identified, 17,055 underwent emergency operations. The overall rate of DOSI in emergency operations was 5.8%. On multivariate analysis, emergency operation was not an independent predictor of DOSI. Predictors of DOSI in emergency operations included age, recent weight loss, steroids, wound and advanced ASA classification. Diabetes was not a predictor of DOSI. In emergency cases, location of resection and anastomosis was not predictive of DOSI. CONCLUSIONS: DOSI are common, occurring in 5.8% of patients after emergency bowel resection andanastomosis. Emergency operation is not a predictor of DOSI. Independent predictors of DOSI include wound and ASA classification, recent weight loss, and steroid use. In emergency operations, the location of resection and anastomosis is not a predictor of DOSI. Skin grafting for the treatment of enterocutaneous fistulas Jessica Korsh, Kristen Aliano, MD, Thomas Davenport, MD, FACS Long Island Plastic Surgical Group, Garden City, NY INTRODUCTION: Postoperative enterocutaneous fistulas occur as a complication in 0.8-2% of abdominal surgeries. The majority of enterocutaneous fistulas are treated by pouching, and in spite of numerous technological advancements, fistula treatment options are fairly limited. Additional enterocutaneous fistula treatments include biologic fibrin glue injections, somatostatin analogs (octreotide), and negative pressure wound therapy (NPWT). The mortality rate ranges from 5-37%. Although skin grafting is employed to treat abdominal wounds, there is minimal literature reviewing the use of skin grafting to treat enterocutaneous fistulas. In this paper, we review our experience with the use of acellular dermal matrices and skin grafting in the treatment of enterocutaneous fistulas.
Vol. 219, No. 4S, October 2014
METHODS: A review of three patient cases who underwent treatment of an enterocutaneous fistula with acellular dermal matrices and skin grafting was performed. RESULTS: All three patients healed well with no recurrence. CONCLUSIONS: Our results support the use of skin grafting and fibrin glue as a successful method of treating enterocutaneous fistulas. VAC use has reduced but not eliminated the need for split-thickness skin grafts or mesh. The use of a dermal matrix and fibrin glue prevents contamination from the enteric fluid from the fistula. Additionally this method prevents the bowel from desiccation and touching surrounding dressings. Our results indicate that the acellular dermal matrix is able to be incorporated into the wound and the fibrin glue secures it and closes the fistula. Laparoscopic splenctomy in isolated blunt traumatic splenic injury Asem S Ghasoup, MBChB, FACS, Turki A Al Qurashi, MD, Omar G Sadieh, MBChB, FACS Saad Specialist Hospital, Al-Khobar, Saudi Arabia and Security Force Hospital, Makkah, Saudi Arabia INTRODUCTION: Minor splenic injuries from blunt trauma can be treated conservatively, whereas high-grade injuries require surgical treatment. Although splenectomy is nowadays performed laparoscopically for the treatment of hematological pathologies, in an emergency is performed through conventional laparotomy, progress in surgical skill and new developments in equipment allow us to manage patients with severe splenic blunt trauma laparoscopically. METHODS: The study included 11 patients with isolated blunt TSI. All patients underwent full history taking, complete physical examination, abdomenial CT for splenic injury grading. Surgical interference was indicated when there was deterioration of patient’s hemodynamic parameters. All splenectomies were performed using 3-trocar approch, intraoperative and postoperative (PO) data were collected. RESULTS: CT examination defined 2 patients of grade V, 5 patients of grade IV, and 4 patients of grade III. All patients passed uneventful intraoperative course without conversion to open splenectomy with a mean operative time of 6020.7 minutes and mean amount of total blood loss of 280.6140.1 ml. All patients required blood transfusion with mean number of blood units of 3.41.1; range: 3-5 units.nine patients passed uneventful postoperative course, one patients developed wound infection and one patient developed chest infection that responded to medical treatment. Mean duration of hospital stay for was 5.72 days. All patients completed their follow-up for a mean duration of 14.14.7 months. No follow-up complications were recorded during follow-up period. CONCLUSIONS: LS is a feasible, safe and effective therapeutic modality for cases of blunt TSI providing short recovery times and hospital stay without extensive morbidities or mortalities.
Scientific Poster Presentations: 2014 Clinical Congress
e189
Lodox statscanner: time is money Julie A Dunn, MD, FACS, Hannah Warren, MD, MPH, Beth Jackson, MD, Gavin I Misner, MD, John Kalbfleisch, PhD East Tennessee State University, Johnson City, TN and University of Colorado Health, Fort Collins, CO INTRODUCTION: In 2006 our Level I trauma center installed a Lodox Statscanner TM allowing total skeletal survey in 13 seconds at 1/20th the radiation dose of a chest x-ray. Despite universal use, drop in the number of additional conventional images was less than expected. We delineate reasons for repetitive imaging and assess diagnostic accuracy of anatomical locations. METHODS: A retrospective chart review of 100 random adult blunt trauma patients was undertaken. Trauma to the skeleton was categorized as: Pelvis, upper extremity, and lower extremity by anatomic site: humerus, radius, ulna, elbow, shoulder, wrist/ hand, femur, tibia, fibula, knee, ankle/foot. Conventional and Lodox images were compared to evaluate accuracy. The role of improper positioning was also evaluated. RESULTS: No repeat images were required of chest or pelvis. Injuries frequently missed with Lodox were: hand (88%), foot (40%), primarily metacarpals, metatarsals, and phalanges. Most frequent additional imaging involved the wrist, hand, tibia, fibula, ankle and foot. Injuries to the humerus, radius, ulna, femur, tibia, and fibula were identified in over 80% of cases. Improper positioning occurred in 74% of upper extremities and 26% of lower extremities. Injury-associated limitations caused 62% of improper positioning for lower extremities. CONCLUSIONS: Lodox provides rapid and accurate characterization of long bone injuries. Despite limitations, Lodox allowed early identification of long bones injuries, allowing more rapid orthopedic activation and decreased time to intervention. With added attention to proper positioning, Lodox accuracy can be enhanced, decreasing the need for additional images, saving time, money, and reducing radiation exposure. Distinct patterns of mortality among the injured elderly: an opportunity for improvement of the processes of care Monica Polcz, BS, Fahim A Habib, MBBS, MPH, FACS, Carolina Orbay, BS, Ivan Puente, MD, FACS, Marko Bukur, MD, FACS, Carlos Prays, BS, Rebecca Wiesenfeld, Joe Catino, MD, FACS, Robyn Farrington-Avila, RN, BSN, MBA-HCM, Jaime A Rodriguez, MD, FACS Broward Health Medical Center, Fort Lauderdale, FL and Florida International University, Miami, FL INTRODUCTION: The geriatric population continues to remain a swiftly mounting demographic in trauma, with mortality rates almost twice that of their younger counterparts. The temporal profile of elderly trauma deaths as it relates to opportunities for interventions and program development has not been clearly described. We hypothesized that the elderly would have a distinct mortality