Gamal Mostafa

Factors affecting intravenous analgesic requirements after colectomy

BACKGROUND The purpose of this study was to determine factors that influence postoperative IV analgesic use after colectomy. STUDY DESIGN We retrospectively evaluated patients who underwent colectomy between January 1997 and December 2000 at our medical center and calculated the amount of postoperative IV narcotics needed in morphine equivalents. Statistical differences (p < 0.05 considered significant) were measured using the Wilcoxon rank-sum test. Correlations were performed using Spearman correlation coefficients, and linear regression analysis was also performed. RESULTS Four hundred eighty-one patients (235 men, 246 women) underwent colectomy; patients had a mean age of 60.6 years (range, 17 to 96 years). Procedures performed included total/subtotal colectomy (10%, n = 49), right colectomy (42%, n = 200), transverse colectomy (3%, n = 12), left/sigmoid colectomy (40%, n = 195), and low anterior resection (4%, n = 17). Laparoscopic colectomy was performed in 53 (11%) patients. Mean postoperative morphine equivalent use was 160.2 mg. Narcotic analgesic use was significantly less for women (p = 0.02), diagnosis of cancer (p = 0.02), and laparoscopic colectomy (p = 0.0001). Patients undergoing a right colectomy required less postoperative narcotics than patients having other types of colectomies (p < 0.02). There was a positive correlation between postoperative narcotic use and operative time (r = 0.14, p = 0.007) and a negative correlation with patient age (r = -0.37, p = 0.0001). Linear regression analysis demonstrated that age (p = 0.0001), female gender (p = 0.04), and laparoscopy (p = 0.001) were independent predictors for decreased narcotic use. CONCLUSIONS Postoperative IV narcotic analgesic use is affected by gender, patient age, indication for colectomy, operative time, type of procedure, and operative technique.

Evaluation of selective treatment of penetrating abdominal trauma.

OBJECTIVE In penetrating abdominal trauma, diagnostic imaging and the application of selective clinical management may avoid negative celiotomy and improve outcome. DESIGN We prospectively observed patients with penetrating abdominal trauma over 15 months and recorded demographics, presentation, imaging, surgical procedure, and outcome. Patients who underwent immediate laparotomy were compared with patients who were observed and/or had a computed tomography (CT) scan. Outcomes of negative versus positive and immediate versus delayed celiotomy were compared. Chi-square and Student t tests were used. A p value of less than 0.05 was considered significant. SETTING A level 1 trauma center. PARTICIPANTS Adult patients who presented with penetrating abdominal injury. RESULTS In all, 100 consecutive patients (mean age, 32 years) were included (male:female, 91:9; gunshot wound:stab wound, 65:35). Overall, 60 immediate and 10 delayed laparotomies were performed; 30 patients did not undergo surgery. Predictors of immediate celiotomy were hypotension (p = 0.03), anteriorly located entrance wounds (p = 0.0005), and transaxial wounds (p = 0.03). Overall morbidity and mortality was 32% and 2%, respectively. The negative celiotomy rate was 25%. Patients with a positive celiotomy had higher morbidity (p = 0.006) and longer hospital length of stay (p = 0.003) compared with negative celiotomy. A CT scan was employed in 32% of patients, with 100% sensitivity and 94% specificity. Delayed celiotomy (10%) did not adversely impact morbidity (p = 0.70) and was 100% therapeutic, with no deaths. CONCLUSION Nonselective immediate celiotomy for penetrating abdominal trauma results in a high rate of unnecessary surgery. Hemodynamically stable patients can safely be observed and/or have contrast CT scans and undergo delayed celiotomy, if indicated. This selective treatment had no adverse effect on patient outcomes and can potentially improve overall outcome.

A review of factors that affect mortality following colectomy.

BACKGROUND The tightening focus on optimizing surgical outcomes has pushed tracking perioperative mortality to the forefront of interest. The goal of this study is to analyze factors affecting mortality after colorectal resection at a single tertiary care center. MATERIALS AND METHODS Data were collected from a prospective database for all patients undergoing a colorectal resection at our institution over a 12-y period. Data points included patient demographics, comorbidities, operative details, clinical presentation, postoperative complications, and mortality. RESULTS A total of 1245 patients were evaluated with 41 deaths (3.3%). Our population was 51% male with an average age of 60.1 ± 15.2 y, mean BMI of 27.5 ± 6.4 kg/m(2), average ASA score of 2.6 ± 0.9, and average of 2.2 ± 1.9 comorbidities. Preoperative factors associated with increased mortality included age, high ASA score, emergent surgery, and the presence of bowel perforation or obstruction (P < 0.05). Intra- and postoperative factors including the transfusion of blood products, length of resection, subtotal colectomy, open versus laparoscopic procedures, the need for reoperation, diagnosis and postoperative complications negatively impact survival (P < 0.05). Stepwise logistic regression demonstrated that high ASA score, emergent procedure, subtotal colectomy, age, obstruction, and open resection as the independent predictors of mortality in a stepwise logistic regression model (P < 0.10). CONCLUSION Preoperative ASA, emergent procedure, age, open procedure, subtotal colectomy, and obstruction were the independent predictors of mortality in our review. Preoperative optimization and counseling of elderly patients with a high ASA score and/or those requiring an emergency operation should be utilized by surgeons in an effort to improve surgical mortality and patient education.

Effect of carbon dioxide pneumoperitoneum and wound closure technique on port site tumor implantation in a rat model

BackgroundThe purpose of this study was to evaluate the effects of carbon dioxide (CO2) pneumoperitoneum and wound closure technique on port site tumor implantation.MethodsA standard quantity of rat mammary adenocarcinoma (SMT2A)was allowed to grow in a flank incision in Wistar-Furth rats (n = 90) for 14 days. Thereafter, 1-cm incisions were made in each animal in three quadrants. There were six control animals. The experimental animals were divided into a 60-min CO2 pneumoperitoneum group (n = 42) and a no pneumoperitoneum (n = 42) group. The flank tumor was lacerated transabdominally in the experimental groups. The three wound sites were randomized to closure of (a) skin; (b) skin and fascia; and (c) skin, fascia, and peritoneum. The abdominal wounds were harvested en bloc on postoperative day 7.ResultsHistologic comparison of the port sites in the pneumoperitoneum and no-pneumoperitoneum groups did not demonstrate a statistically significant difference in tumor implantation for any of the closure methods. Evaluation of the closure techniques showed no statistical difference between the pneumoperitoneum group and the no-pneumoperitoneum group in the incidence of port site tumor implantation. Within the no-pneumoperitoneum group, there was a significant increase (p = 0.03) in tumor implantation with skin closure alone vs all three layers. Additionally, when we compared all groups by closure technique, the rate of tumor implantation was found to be significantly higher (p = 0.01) for skin closure alone vs closure of all three layers.ConclusionsThis study suggests that closure technique may influence the rate of port site tumor implantation. The use of a CO2 pneumoperitoneum did not alter the incidence of port site tumor implantation at 7 days postoperatively.

The hazard of scattered radiation in a trauma intensive care unit.

OBJECTIVE Patients admitted to the trauma intensive care unit (TICU) often require bedside imaging procedures such as radiographs, fluoroscopic placement of enteral feeding tubes, and insertion of vena cava filters. The potential for scattered radiation exposure is a concern to healthcare workers. Our studys purpose was to measure the level of scattered ionizing radiation present in a TICU. DESIGN AND SETTING This prospective study was conducted over 3 months in an open-design, ten-bed TICU of a Level I trauma center. INTERVENTIONS AND MEASUREMENTS Fifteen dosimeters were placed in selected areas of the TICU to measure the amount of scattered radiation present. Standard radiation protection precautions were used throughout the study period. At the end of each month, data from the dosimeters were sent to the manufacturer for analysis. MAIN RESULTS One thousand seventy-four radiologic studies were performed at the bedside during the study period (803 portable chest radiographs, 103 abdominal radiographs, 303 extremity radiographs, 223 spine radiographs, and 15 fluoroscopic procedures). Dosimetry analysis showed <5 mrem (1/1000 roentgen equivalent in man) scattered radiation per month (<60 mrem/year) in each of the monitored areas. All monitored areas measured <2 mrem per week of scattered radiation when adjusted for occupancy. CONCLUSIONS The level of scattered radiation in our TICU is less than the recommended allowable exposure of <100 mrem/year, indicating that radiation exposure is not a significant occupational hazard in our TICU, even in the setting of frequent use of bedside imaging studies.

Elective laparoscopic splenectomy for grade III splenic injury in an athlete.

The safety and efficacy of laparoscopic splenectomy in the management of benign hematologic diseases is well established. Laparoscopic splenectomy for splenic trauma has been reported infrequently, and most consider a minimally invasive approach to be contraindicated. A heralded, standout college football player who sustained a grade III splenic laceration while playing football was referred for laparoscopic splenectomy so that he could convalesce rapidly, complete his final year of athletic eligibility, and prepare for the National Football League draft. The ethical issues regarding this patients care were discussed extensively with the patient, his parents, and the hospital administration. After informed consent, the patient underwent a laparoscopic splenectomy with no intraoperative complications. He was discharged 20 hours after surgery. The patient played in a collegiate football game 12 days after surgery, was drafted into the National Football League 9 months later, and was on the opening day roster 12 months after his surgery. We do not advocate laparoscopic splenectomy for injuries to the spleen as the standard of care. This case, however, illustrates the potential for laparoscopic surgery to provide a safe and feasible alternative to traditional surgical approaches.

Traumatic carotid cavernous fistula

A 46-year-old man presented with a closed head injury from a motor vehicle crash. Six days after the injury, he complained of pain in his right eye and swelling of the right orbit. Physical examination revealed 6-mm proptosis associated with chemosis. A bruit was audible over the right orbit. No cranial nerves or extremity neurological deficits were evident. Cerebral angiography showed a posttraumatic carotid cavernous fistula (CCF) (A, bottom arrow) with direct opacification of the cavernous sinus and early filling of the superior ophthalmic veins (A, top arrow). Subsequently, the patient underwent transarterial coil embolization (B, arrow). The orbital bruit disappeared and chemosis rapidly decreased. He made uneventful recovery and remained without focal neurologic deficit. CCF is a communication between the cavernous portion of the carotid artery and the venous plexus of the cavernous sinus. In contrast to the spontaneous variety, post-traumatic CCF is usually from direct shunting between the carotid artery and the cavernous sinus with high flow and pressure. Although CCF can be caused by penetrating cranial injuries, severe blunt trauma is the most common mechanism. Fistulas usually appear within a few weeks after the injury with symptoms and signs related to increased venous pressure transmitted through the valveless ophthalmic veins. Orbital bruit is invariably audible and pulsating exophthalmos with chemosis are often present. With post-traumatic CCF, cerebral angiography reveals direct opacification of an enlarged cavernous sinus, early filling of ophthalmic veins, and diminished opacification of the distal arterial system (A). Complications of CCF include cranial (most commonly the sixth) nerve palsy, progressive visual impairment, and subarachnoid hemorrhage. The goal of management of CCF is occlusion of the fistula while maintaining carotid artery patency. Although surgical treatment was previously advocated, several endovascular procedures have recently been used to achieve this goal. Because percutaneous embolization of CCF effects occlusion of the fistula and carries low morbidity and mortality, it is currently considered the treatment of choice.

Outcomes of right- compared with left-side colectomy.

Right colon resections are perceived as less morbid than left colon resections. The purpose of this study was to determine the differences in outcomes between right-and left-side colon resections. We reviewed 420 consecutive open colectomies over 4 years. Patient demographics, surgical indications, intraoperative variables, and outcomes were collected. Two hundred twenty-three right colectomies (RCs) were compared with 197 left colectomies (LCs). RCs were more often required for cancer (111 vs 65, P < .001) and LCs for diverticular disease (10 vs 90, P < .001). LCs were more often performed emergently (36% vs 23%, P = .004) and required longer mean operative times (149 minutes vs 130 minutes, P = .004). Complications and mortality in the two groups were equal statistically. In the emergent colectomy subset, LCs were associated with greater intraoperative blood loss (315 vs 201 mL, P = .02) but fewer complications (11% vs 17%, P = .003).

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.

Images in clinical medicine. Ileocecal intussusception.

n engl j med 361;24 nejm.org december 10, 2009 e55 A 45-year-old man with no notable medical or surgical history presented with a 24-hour history of intense pain in the right side of the abdomen with associated nausea and vomiting. He reported having had similar but much less severe episodes during the previous 6 months. Results of initial laboratory tests were unrevealing. Physical examination showed moderate abdominal distention. Computed tomographic scans of his abdomen revealed an ileocecal intussusception (Panel A, arrow) with a pathologic mass, 2.5 cm in diameter, at the apex, also known as the lead point (Panel B, arrow). Diagnostic laparoscopy was performed, and the diagnosis of intussusception was confirmed. Laparoscopically assisted ileocecal resection with primary anastomosis was performed. Gross inspection of the specimen showed a pedunculated lipoma within the terminal ileum. The patient had a rapid recovery, with complete resolution of his symptoms.