Andrea Pakula

Acute Kidney Injury in the Critically Ill Patient: A Current Review of the Literature.

Purpose: A comprehensive review of the literature to provide a focused and thorough update on the issue of acute kidney injury (AKI) in the surgical patient. Methods: A PubMed and Medline search was performed and keywords included AKI, renal failure, critically ill, and renal replacement therapy (RRT). Principal Findings: A common clinical problem encountered in critically ill patients is AKI. The recent consensus definitions for the diagnosis and classification of AKI (ie, Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease/Acute Kidney Injury Network) have enabled us to standardize the severity of AKI and facilitate strategies for prevention. These strategies as well as treatment modalities of AKI are discussed. We provide a concise overview of the issue of renal failure. We describe strategies for prevention including types of fluids used for resuscitation, timing of initiation of RRT, and different treatment modalities currently available for clinical practice. Conclusions: Acute kidney injury is a common problem in the critically ill patient and is associated with worse clinical outcomes. A standardized definition and staging system has led to improved diagnosis and understanding of the pathophysiology of AKI. There are many trials leading to improved prevention and management of the disease.

A case of a traumatic chyle leak following an acute thoracic spine injury: successful resolution with strict dietary manipulation

BackgroundChylothorax is a rare form of pleural effusion that can be associated with both traumatic and non-traumatic causes. Thoracic duct ligation is often the treatment of choice in postsurgical patients; however the optimal treatment of this disease process after traumatic injury remains unclear [1]. We present a rare case of a thoracic duct injury secondary to a blunt thoracic spine fracture and subluxation which was successfully treated non-operatively.Case PresentationA 51 year old male presented as a tier one trauma code due to an automobile versus bicycle collision. His examination and radiographic work-up revealed fractures and a subluxation at the third and fourth thoracic spine levels resulting in paraplegia. He also sustained bilateral hemothoraces secondary to multiple rib fractures. Drainage of the left hemothorax led to the diagnosis of a traumatic chylothorax. The thoracic spine fractures were addressed with surgical stabilization and the chylothorax was successfully treated with drainage and dietary manipulation.ConclusionsThis unusual and complex blunt thoracic duct injury required a multidisciplinary approach. Although the spine injury required surgical fixation, successful resolution of the chyle leak was achieved without surgical intervention.

Multi-institutional, prospective, observational study comparing the Gastrografin challenge versus standard treatment in adhesive small bowel obstruction

INTRODUCTION Existing trials studying the use of Gastrografin for management of adhesive small bowel obstruction (SBO) are limited by methodological flaws and small sample sizes. We compared institutional protocols with and without Gastrografin (GG), hypothesizing that a SBO management protocol utilizing GG is associated with lesser rates of exploration, shorter length of stay, and fewer complications. METHODS A multi-institutional, prospective, observational study was performed on patients appropriate for GG with adhesive SBO. Exclusion criteria were internal/external hernia, signs of strangulation, history of abdominal/pelvic malignancy, or exploration within the past 6 weeks. Patients receiving GG were compared to patients receiving standard care without GG. RESULTS Overall, 316 patients were included (58 ± 18 years; 53% male). There were 173 (55%) patients in the GG group (of whom 118 [75%] successfully passed) and 143 patients in the non-GG group. There were no differences in duration of obstipation (1.6 vs. 1.9 days, p = 0.77) or small bowel feces sign (32.9% vs. 25.0%, p = 0.14). Fewer patients in the GG protocol cohort had mesenteric edema on CT (16.3% vs. 29.9%; p = 0.009). There was a lower rate of bowel resection (6.9% vs. 21.0%, p < 0.001) and exploration rate in the GG group (20.8% vs. 44.1%, p < 0.0001). GG patients had a shorter duration of hospital stay (4 IQR 2–7 vs. 5 days IQR 2–12; p = 0.036) and a similar rate of complications (12.5% vs. 17.9%; p = 0.20). Multivariable analysis revealed that GG was independently associated with successful nonoperative management. CONCLUSION Patients receiving Gastrografin for adhesive SBO had lower rates of exploration and shorter hospital length of stay compared to patients who did not receive GG. Adequately powered and well-designed randomized trials are required to confirm these findings and establish causality. LEVEL OF EVIDENCE Therapeutic, level III.

The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction

BACKGROUND The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) was validated at a single institution. We aimed to externally validate the AAST ASBO grading system using the Eastern Association for the Surgery of Trauma multi-institutional small bowel obstruction prospective observational study. METHODS Adults (age ≥ 18) with (ASBO) were included. Baseline demographics, physiologic parameters (heart rate, blood pressure, respiratory rate), laboratory tests (lactate, hemoglobin, creatinine, leukocytosis), imaging findings, operative details, length of stay, and Clavien-Dindo complications were collected. The AAST ASBO grades were assigned by two independent reviewers based on imaging findings. Kappa statistic, univariate, and multivariable analyses were performed. RESULTS There were 635 patients with a mean (±SD) age of 61 ± 17.8 years, 51% female, and mean body mass index was 27.5 ± 8.1. The AAST ASBO grades were: grade I (n = 386, 60.5%), grade II (n = 135, 21.2%), grade III (n = 59, 9.2%), grade IV (n = 55, 8.6%). Initial management included: nonoperative (n = 385; 61%), laparotomy (n = 200, 31.3%), laparoscopy (n = 13, 2.0%), and laparoscopy converted to laparotomy (n = 37, 5.8%). An increased median [IQR] AAST ASBO grade was associated with need for conversion to an open procedure (2 [1–3] vs. 3 [2–4], p = 0.008), small bowel resection (2 [2–2] vs. 3 [2–4], p < 0.0001), postoperative temporary abdominal closure (2 [2–3] vs. 3 [3–4], p < 0.0001), and stoma creation (2 [2–3] vs. 3 [2–4], p < 0.0001). Increasing AAST grade was associated with increased anatomic severity noted on imaging findings, longer duration of stay, need for intensive care, increased rate of complication, and higher Clavien-Dindo complication grade. CONCLUSION The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research focused on optimizing preoperative diagnosis and management algorithms. LEVEL OF EVIDENCE Prognostic, level III.

A rare case of chronic traumatic diaphragmatic hernia requiring complex abdominal wall reconstruction

Highlights • We present case of chronic traumatic diaphragmatic hernia.• Traumatic diaphragmatic hernia are rare and under diagnosed.• Chronic hernia may require complex abdominal reconstruction.• Computed tomography has diagnostic characteristics.

A rare case of fusiform celiac artery aneurysm after penetrating trauma

Highlights • Celiac artery aneurysm make up a small number of visceral artery aneurysms.• Penetrating trauma is a common cause of visceral artery aneurysms.• Endovascular management is becoming commonplace for these lesions.

Do acute care surgeons need bariatric surgical training to ensure optimal outcomes in obese patients with nonbariatric emergencies

INTRODUCTION Acute care surgeons care for the entire breadth of the American adult population, including obese patients. As the population gets heavier, more patients will present to acute case surgeons with nonbariatric surgical emergencies. Do these surgeons need bariatric training to properly care for obese population? OBJECTIVES To evaluate our experience in obese population requiring acute surgery and compare outcomes based on surgeon expertise in bariatric surgery. SETTING Community teaching hospital, United States. METHODS Retrospective review of obese patients requiring acute surgical intervention. Surgeons were classified as bariatric surgeons (B, n = 2) versus nonbariatric surgeons (NB, n = 4). Demographic characteristics, co-morbidities, and outcomes based on surgeon training were compared. RESULTS Two hundred three patients comprised the cohort. The mean body mass index was 37 ±6 kg/m2. The majority of procedures were laparoscopic (cholecystectomies n = 75, appendectomies n = 45). The remaining nonroutine laparoscopic cases were intestinal obstructions (n = 9), incarcerated hernias (n = 17), traumatic injuries (n = 48), and intestinal ischemia or perforation (n = 9). Bariatric surgeons performed 35% of cases, and risk profiles were similar between groups. Operative times were similar for cholecystectomies and appendectomies. Bariatric surgeons performed more nonroutine cases laparoscopically (7% B versus 2% NB, P = .001). Surgical site infections were low (2% B versus 4% NB, P = .4). Hospital length of stay was higher in the NB group at 9 ± 9 days versus 5 ± 4 days for B (P = .05). Mortality was 5%. CONCLUSIONS Acute surgical procedures were performed in obese patients. Bariatric expertise favorably affected length of stay and the application of laparoscopy. Bariatric expertise may improve outcomes in nonbariatric emergencies, but further study is warranted.