Ivan Puente

Open Versus laparoscopic appendectomy : a prospective randomized comparison

ObjectiveThe authors compare open and laparoscopic appendectomy in a randomized fashion with regard to length of operation, complications, hospital stay, and recovery time. MethodsAdult patients (older than 14 years of age) with the diagnosis of acute appendicitis were randomized to either open or laparoscopic appendectomy over a 9-month period. All patients received preoperative antibiotics. The operative time was calculated as beginning with the incision and ending when the wound was fully closed. Patients that were converted from laparoscopic to open appendectomy were considered a separate group. Return to normal activity and work were determined by questioning during postoperative clinic, telephone, or mailed questionnaire. ResultsThere was a total of 169 patients randomized, 88 to the open and 81 to the laparoscopic group. The groups were similar demographically. Of the 81 laparoscopic patients, 13 (16%) were converted to open. In the open group, 70 patients (79.5%) had acute appendicitis and 21 (23.9%) had perforative appendicitis. In the laparoscopic group, 62 patients (76.5%) had acute appendicitis and 10 (12.3%) had perforative appendicitis. There was no statistical difference in the return to activity or work between the laparoscopic and open groups. The operative time was significantly longer in the laparoscopic group (102.2 minutes vs. 81.7 minutes, p < 0.01). The hospital stay of 2.2 days in the laparoscopic group and 4.3 days in the open group was statistically different (p = 0.007). There was no difference in the hospital stay for those with acute appendicitis (1.89 days vs. 2.61 days, p = 0.067) compared with those with a normal appendix but with pelvic inflammatory disease (1.1 days vs. 2.3 days, p = 0.11). There was a significant difference in patients with perforative appendicitis (1.5 days vs. 9.5 days, p < 0.01). The hospital cost for patients having laparoscopic appendectomy was

Management Of Lower Extremity Arterial Trauma

6077 and for an open appendectomy

Laparoscopic-assisted colostomy closure after Hartmann's procedure.

7227 (p = 0.164). There were no increased complications associated with the laparoscopic technique. ConclusionLaparoscopic appendectomy is comparable to open appendectomy with regard to complications, hospital stay, cost, return to activity, and return to work. There was a greater operative time involved with the laparoscopic technique. Laparoscopic appendectomy does not offer any significant benefit over the open approach for the routine patient with appendicitis.

Laparoscopy in 121 consecutive patients with abdominal gunshot wounds

Extremity vascular trauma is common in most urban trauma centers and controversy remains about the optimal management of arterial injuries. We examined the records of 188 patients who had lower extremity arterial trauma from September 1987 to April 1992 to help clarify these issues. There were 142 (75.5%) gunshot wounds, 18 (9.6%) stab wounds, 5 (2.7%) shotgun wounds, and 23 (12.2%) patients with blunt trauma. There were 43 (22.9%) associated venous injuries. There were 10 repair failures in the acute postoperative period. There were no repair failures for the iliac artery. Three failures involved the superficial femoral artery (SFA), six were popliteal, and one tibial. Vein and polytetrafluoroethylene (PTFE) grafts were used to repair the SFA with equal success. Repair of the popliteal artery with PTFE failed in four of five cases, while vein grafts failed in only 2 of 19 cases (p < 0.01). Graft failure was associated with blunt trauma in 8 of 23 patients (35%), and always resulted in amputation. Penetrating injuries accounted for only 2 of 165 (1.2%) failures and were successfully redone with no amputations. Venous injury was present in all SFA failures. Popliteal vein injury was present in two PTFE and two vein grafts that failed. There were no infections of vein or PTFE grafts. In conclusion, PTFE and vein have equal graft patency for the repair of the iliac and femoral arteries. However, the patency of PTFE was significantly worse in the popliteal location. Vein grafts should be used for repair of this vessel. Graft failure and amputation were more common with popliteal and tibial injuries from blunt mechanisms.(ABSTRACT TRUNCATED AT 250 WORDS)

Negative Laparotomy in Abdominal Gunshot Wounds: Potential Impact of Laparoscopy

PURPOSE: The aim of the study was to review our experience with colostomy closure after Hartmanns procedure and the possible impact of laparoscopic colostomy closure. METHODS: A retrospective review of hospital stay after colostomy closure by laparotomy in the last four years was conducted. A chart review of patients undergoing laparoscopic colostomy closure after Hartmanns procedure since the introduction of operative laparoscopy at our institution was also done. RESULTS: One hundred twenty patients had colostomy closure carried out by the trauma service at the University of Miami/Jackson Memorial Hospital. In thirty-seven patients, colostomy closure was associated with other surgical procedures such as ventral herniorrhaphy, delayed closure of the open abdomen, ureteroneocystostomy, and so forth, or they underwent loop colostomy closure. These patients were excluded from further review. Sixty-five patients underwent reversal of Hartmanns procedure by laparotomy. They had an average hospital stay of 9.5 days (range, 6 to 34 days). This group of patients had colostomy closure prior to the introduction of operative laparoscopy in our institution. With increased laparoscopy experience, laparoscopically assisted Hartmanns reversal has been attempted in 18 patients and completed in 14 patients. The average hospital stay in the laparoscopically completed group was 6.3 days (range, 4 to 10 days). This group had a 0 percent mortality and a 14.3 percent morbidity. This compares favorably to recently reported series of colostomy closure by laparotomy. CONCLUSION: Laparoscopically assisted Hartmanns reversal results in comparable morbidity, but may be associated with shorter hospital stay when compared with laparotomy.

Probable cause in helicopter emergency medical services crashes: what role does ownership play?

OBJECTIVE The purpose of this study was to evaluate the sensitivity, specificity, and predictive value of diagnostic laparoscopy (DL) in a large group of stable patients with abdominal gunshot wounds (ABGSWs). DESIGN This study was a prospective case series developed by management protocol. MATERIALS AND METHODS In a 2 1/2-year period, DL was performed in 121 consecutive patients who were hemodynamically stable with ABGSWs and met protocol criteria. This represented 18% of all patients with ABGSWs seen in this period at the Ryder Trauma Center. The evaluation was conducted to determine peritoneal violation, the presence of intra-abdominal blood, and the need for exploration. MEASUREMENTS AND MAIN RESULTS There were 42 (35%) positive and 79 (65%) negative DLs. In patients with positive DL, 39 (92.8%) had exploratory laparotomy. In this group, 32 (82%) had therapeutic laparotomy, 6 (15.4%) had nontherapeutic laparotomy, and 1 (2.5%) had a negative laparotomy. In this patient, DL was felt to be inadequate by the attending surgeon, although no penetration or intraperitoneal blood were present, and a negative laparotomy was done. This represents a failure rate of 0.8%. There were 3 (7.2%) positive DLs, in whom laparotomy was not performed. These patients had isolated nonbleeding liver injuries, and nontherapeutic laparotomy was successfully avoided. The negative DL group was divided into 47 patients (60%) with isolated ABGSWs, and 32 patients (40%) with associated injuries, mostly orthopedic and thoracic. There were no false-negative DLs and no delayed laparotomies in these 121 patients. There was no mortality in this study group. The sensitivity for peritoneal penetration was 100%, and the specificity was 98.7%. The positive predictive value was 97.6%, and the negative predictive value was 100%. In deciding on need for laparotomy (i.e., injury requiring repair), DL had a positive predictive value of 82%; more importantly, the negative predictive value was 100%. CONCLUSIONS In stable patients with ABGSWs and questionable intra-abdominal injury, DL can be safely used. It is highly sensitive and specific. It can effectively reduce the incidence of negative and nontherapeutic laparotomies, and the overall morbidity and hospital stay in this group of patients.

Does unit designation matter? A dedicated trauma intensive care unit is associated with lower postinjury complication rates and death after major complication

OBJECTIVE To evaluate the morbidity and hospital stay resultant from negative exploratory laparotomy (NL) for abdominal gunshot wounds (ABGSWs) and the potential impact the use of diagnostic laparoscopy (DL) could have on these variables. DESIGN A retrospective study was conducted. MATERIALS AND METHODS The charts of all patients with ABGSWs over a 4-year period were reviewed. Data was collected on injuries, rate of NL, morbidity and hospital stay. This was compared to a subsequent group of patients with ABGSWs managed with a DL protocol. MEASUREMENTS AND MAIN RESULTS Over a 4-year period, 817 patients had exploratory laparotomy (EL) for ABGSWs. The NL rate was 12.4% (101 of 817); 69 of these patients had no associated injury or other procedures. They had a 22% morbidity and an average hospital stay of 5.1 days. Subsequently, 85 patients with ABGSWs underwent DL. This group was similar to the EL group and would have undergone EL prior to the introduction of DL at our institution. In this group, 34 patients had no associated injury or other procedures. They had a 3% morbidity, and their average hospital stay was 1.4 days. The morbidity and hospital stay were statistically significantly reduced (p < 0.01) in patients with negative DL versus NL. CONCLUSIONS These data demonstrate that NL is associated with a high morbidity and long hospital stay. The use of DL can reduce the rate of NL, and result in lower morbidity and shorter hospital stay in patients with ABGSWs.

Laparoscopic Assisted Colorectal Surgery

BACKGROUND The National Transportation Safety Board (NTSB) ranks helicopter emergency medical services (HEMS) as one of the most perilous occupations in the United States, with improvements in its safety of highest priority. As many injured patients are transported by helicopter, this is of particular concern to the trauma community. The use of HEMS is associated with a heightened degree of inherent risk. We hypothesized that this risk is not uniform and varies with the entity providing HEMS, specifically, commercial versus public safety providers. METHODS The NTSB accident database was queried to identify all HEMS-involved events for the 15-year period 1998 to 2012. The NTSB investigation report was reviewed to obtain crash details including probable cause. These were analyzed on the basis of HEMS ownership. Statistical analyses were performed using analysis of variance and Fisher’s exact test as appropriate. RESULTS During the study period, 139 (6.8%) of 2,040 crashes involved HEMS and occurred across 134 cities in 37 states, killing 120 and seriously injuring 146. Of these, 118 involved commercial, 14 not-for-profit, and 7 public safety HEMS. Analyzed in 5-year blocks, no decrease in crash incidence was seen (p = 0.7, analysis of variance). Human and pilot errors were significantly more common among commercial HEMS compared with public safety HEMS (91 of 118 vs. 2 of 7, p = 0.013, and 75 of 116 vs. 1 of 7, p = 0.017, Fisher’s exact test). Conditions for which training was not adequate, limited resources, inadequate equipment, and the undertaking of suboptimal trips were identified as key factors. Trauma patients were involved in 34 transports (24.5%), with a fatal or serious outcome in 68 crew/patients on 12 flights. CONCLUSION Potentially preventable human and pilot error–related HEMS crashes are significantly more frequent among commercial compared with public safety providers. Deficiencies in training, reduced availability of equipment and resources, as well as questionable flight selection seem to play a key role. LEVEL OF EVIDENCE Epidemiologic study, level III.

Reclosure of the open abdomen

BACKGROUND Recent data suggest that specialty intensive care units (ICUs) have outcomes better than those of mixed ICUs. The cause for this apparent discrepancy has not been well established. We hypothesized that trauma patients admitted to a dedicated trauma ICU (TICU) would have a lower complication rate as well as death after complication (failure to rescue [FTR]). METHODS This was a retrospective review of the ICUs of two Level I trauma centers covered by one group of surgical intensivists. One center has a dedicated TICU, while the other has a mixed ICU. Demographic and clinical characteristics were stratified into TICU and ICU groups. The primary outcomes were postinjury complications and FTR. Multivariate regression was used to derive factors associated with complications and FTR. RESULTS During the 5-year study period, 3,833 patients were analyzed. TICU patients were older (57.8 vs. 47.0 years, p < 0.0001), had higher Charlson score (2 vs. 1, p = 0.001), had more severe head injuries (Head Abbreviated Injury Scale [AIS] score ≥ 3, 50.0% vs. 37.5%, p < 0.0001), and had greater injury burden (Injury Severity Score [ISS] > 16, 49.6% vs. 38.6%, p < 0.0001) than those admitted to the mixed ICU. Need for immediate operative intervention was similar (18.0% vs. 17.6%, p = 0.788). Overall complications were significantly higher in trauma patients admitted to the mixed ICU (27.5% vs. 17.0%, p < 0.0001), as well as FTR (3.7% vs. 1.8%, p < 0.0001). Trauma patients admitted to a dedicated TICU had significantly lower chance of developing a postinjury complication (adjusted odds ratio [AOR], 0.5; p < 0.0001), FTR (AOR, 0.3; p < 0.0001), and overall mortality (AOR, 0.4; p < 0.0001). CONCLUSION Admission of critically ill trauma patients to a TICU staffed by a surgical intensivist is associated with a lower complication rate and FTR. Factors such as trauma nursing experience, education, and unit management structure should be further explored to elucidate the observed improved outcomes. LEVEL OF EVIDENCE Prognostic study, level III.