Blair A. Wormer

Vasopressor use after initial damage control laparotomy increases risk for anastomotic disruption in the management of destructive colon injuries

BACKGROUND Management of destructive colon injuries during damage control (DC) laparotomy is debated. The authors reviewed a single institutions experience with destructive colon injuries to identify risk factors for anastomotic failure after colon reconstruction. METHODS The authors identified all trauma patients sustaining destructive colon injuries between 2002 and 2011 from their medical centers trauma registry. Anastomotic leak was defined as suture or staple line disruption or enteral fistula formation. RESULTS Of 171 identified patients, 68 had DC procedures, 41 (60%) had subsequent anastomoses performed during the same hospitalization, and 27 (40%) were diverted. The colon anastomotic leak rate in patients who underwent DC laparotomy was higher than in patients who were reconstructed at the primary operation in a non-DC setting (17% vs 6%, P = .09). The use of vasopressors after the initial DC operation more than quadrupled the leak rate to 50% (P = .02). CONCLUSIONS Colonic anastomotic disruptions yield deadly consequences, and diversion rather than anastomosis should be used in patients who require vasopressor support after the initial DC procedure.

Improving overtriage of aeromedical transport in trauma: a regional process improvement initiative.

BACKGROUND Aeromedical transport (AMT) is an effective but costly means of rescuing critically injured patients. Although studies have shown that it improves survival to hospital discharge compared with ground transportation, an efficient threshold or universal criteria for this mode of transport remains to be established. Herein, we examined the effect of implementing a Trauma Advisory Committee (TAC) initiative focused on reducing AMT overtriage (OT) rates. METHODS TAC outreach coordinators implemented a process improvement (PI) initiative and collected data prospectively from January 2007 to December 2011. OT was defined as patients who were airlifted from scene and later discharged from the emergency department. Serving as liaisons to surrounding counties, TAC outreach coordinators conducted quarterly PI meetings with local emergency medical service agencies. Patients were grouped into those who were airlifted from TAC counties versus counties outside TAC’s jurisdiction (non-TAC). Standard statistical methods were used. RESULTS From 2007 to 2011, 3,349 patients were airlifted from 30 counties, 1,427 (43%) from TAC counties and 1,922 (57%) from non-TAC counties. The OT rates from TAC counties declined compared with non-TAC counties each year and reached statistical significance in 2008 (17% vs. 23%, p < 0.05), 2009 (11% vs. 17%m p < 0.05), and 2011 (6% vs. 12%, p < 0.05). The reduction in OT continued over the study duration, with improvement in TAC counties compared with previous years. CONCLUSION Implementation of a regional TAC PI initiative focused on OT issues led to a more efficient use of AMT. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

Reducing Postoperative Abdominal Bulge Following Deep Inferior Epigastric Perforator Flap Breast Reconstruction with Onlay Monofilament Poly-4-Hydroxybutyrate Biosynthetic Mesh.

Background The purpose of this study was to evaluate the use of a biosynthetic mesh onlay on reducing postoperative abdominal bulge following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods All patients undergoing DIEP reconstructions from January, 2010 to January, 2014 at a tertiary center were reviewed. Patients were divided into two groups for comparison based on whether a biosynthetic mesh onlay (Phasix [monofilament poly‐4‐hydroxybutyrate], Bard Inc., Warwick, RI) was used for reinforcement of the anterior rectus fascia. Rates of postoperative abdominal bulge were compared between the groups utilizing standard statistical methods. Results During the study period, 319 patients underwent 553 DIEP reconstructions, 160 (50.2%) used mesh and 159 (49.8%) did not (nonmesh). The mean follow‐up was 16.4 ± 11.1 months. There was no difference in age (49 ± 9.3 years), current tobacco use, diabetes, or mean body mass index (BMI, 29.4 ± 4.4) between the mesh and nonmesh groups (p > 0.05); however, there was a higher proportion of obese patients (BMI > 30) in the mesh group (45.0 vs. 33.3%; p = 0.03). Abdominal bulge rate following DIEP with mesh was lower than the nonmesh group (0 vs. 5.0%; p = 0.004). In the entire sample, 234 (73.4%) underwent bilateral DIEP and 85 (26.6%) underwent unilateral DIEP. In unilateral DIEP patients, the bulge rate was similar between the mesh and nonmesh groups (0 vs. 4.4%; p > 0.05); however, in bilateral DIEP patients, the bulge rate was lower in the mesh group compared with a nonmesh group (0 vs. 5.5%; p = 0.008). Conclusion Reinforcement of the anterior rectus with an onlay monofilament poly‐4‐hydroxybutyrate biosynthetic mesh may reduce the risk of postoperative bulge rate in patients undergoing DIEP reconstruction.

Emphysematous Gastritis with Delayed Gastric Perforation

IntroductionEmphysematous gastritis (EG) is a rare infection of the stomach caused by gas-producing organisms. It is often associated with high mortality, and operative intervention is avoided unless medical management fails to control sepsis, or patients develop gastric perforation.DiscussionWe present the case of a 24-year-old female with poorly controlled diabetes who presented with persistent vomiting and severe hyperglycemia. Prompt diagnosis of EG was obtained when computed tomography of the abdomen revealed gas throughout her stomach wall and portal venous system. She was treated with antibiotics, bowel rest, and close observation. The patient returned with contained gastric perforation and was successfully managed without surgery. This case demonstrates that delayed gastric perforation as a complication of EG can be successfully managed without surgery, and in selected cases, gastric perforation is not an absolute indication for surgery.