Mickey M. Ott

Eastern Association for the Surgery of Trauma: A Review of the Management of the Open Abdomen-Part 2 "Management of the Open Abdomen"

During the course of the last 30 years, several authors have contributed their clinical experience to the literature in an effort to describe the various management strategies for the appropriate use of the open abdomen technique. There remains a great degree of heterogeneity in the patient population, and the surgical techniques described. The open abdomen technique has been used in both military and civilian trauma and vascular and general surgery emergencies. Given the lack of consistent practice, the Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Committee convened a study group to establish recommendations for the use of open abdomen techniques in both trauma and nontrauma surgery. This has been a major undertaking and has been divided into two parts. The EAST practice management guidelines for the open abdomen part 1 “Damage Control” have been published.1 During the development of the open abdomen part II “Management of the Open Abdomen,” the current literature remains contentious at best, current methods of treatment continue to change rapidly, and patient populations are so heterogeneous that clear recommendations could not be provided. What follows is a thorough review of the current literature for the management of the open abdomen: part 2 “Management of the Open Abdomen” and provides clinical direction regarding the following specific topics.

Colon Anastomosis After Damage Control Laparotomy: Recommendations From 174 Trauma Colectomies

BACKGROUND Primary colonic anastomosis in trauma patients has been demonstrated to be safe. However, few studies have investigated this in the setting of damage control laparotomy. We hypothesized that colonic anastomosis for trauma patients requiring an open abdomen (OA) would have a higher anastomotic leak (AL) rate when compared with patients having an immediate abdominal closure following trauma laparotomy. METHODS We performed a cohort comparison study of all trauma patients who underwent colectomy, between the years 2004 and 2009. Exclusion criteria were mortality within 24 hours of admission or colectomy for indications unrelated to injury. Data collected included age, gender, injury severity score, mechanism, length of stay, and mortality. Multivariable logistic regression was performed to assess the relationship of OA to our primary outcome measure, AL. RESULTS Totally, 174 patients met study criteria. Fecal diversion was performed in 58 patients, and colonic anastomosis was performed in the remaining 116 patients. Patients with OA had a clinically significant increase in AL rate compared with immediate abdominal closure (6% vs. 27%, p=0.002). Logistic regression demonstrated that OA was independently associated with AL, with OA patients having more than a sixfold increase in odds of AL compared with those who were closed (odds ratio=6.37, p=0.002, area under the receiver operator curve=0.72). Transfusion requirement and left-sided anastomosis were risk factors for leak. CONCLUSIONS Patients with a colonic anastomosis and an OA have an unacceptably high leak rate compared with those who undergo reconstruction with immediate closure. Given the significant risk of AL, colonic anastomosis should not be routinely performed in patients with OA.

Antiplatelet and anticoagulation therapies do not increase mortality in the absence of traumatic brain injury.

BACKGROUND : As the population continues to age, the number of patients undergoing traumatic injury while on antiplatelet or anticoagulation therapies is increasing. Mortality has been shown to increase in traumatic brain injury patients on warfarin therapy. Whether this increased mortality is seen in trauma patients without traumatic brain injury remains controversial. We investigated whether patients on antiplatelet and/or anticoagulation therapy were at increased risk of death from blunt traumatic injury in the absence of head injury. METHODS : A retrospective review of our Level I trauma center database was performed from 2002 to 2007. Inclusion criteria included all patients older than 60 years admitted to the trauma service. Only patients with a computed tomography scan negative for intracranial injury were analyzed. RESULTS : Two hundred twelve patients were found, of which 67 were found to be taking aspirin, warfarin, clopidogrel, or a combination of the three. Injury Severity Score (21 vs. 21), length of stay (11 days vs. 9 days), intensive care unit days (5 days vs. 4 days), and deaths (13% vs. 10%) were similar between those patients on antiplatelet/anticoagulation therapy and those who were not. CONCLUSION : In the absence of traumatic brain injury, the use of preinjury antiplatelet and/or anticoagulation therapy does not significantly increase the risk of mortality in the trauma patient. As the number of active seniors rises, this patient population will continue to present to the trauma service. To the best of our knowledge, this study is one of the largest addressing this question, and the only study examining the addition of antiplatelet therapy.

The first 72 hours of brain tissue oxygenation predicts patient survival with traumatic brain injury.

BACKGROUND: Utilization of brain tissue oxygenation (pBtO2) is an important but controversial variable in the treatment of traumatic brain injury. We hypothesize that pBtO2 values over the first 72 hours of monitoring are predictive of mortality. METHODS: Consecutive, adult patients with severe traumatic brain injury and pBtO2 monitors were retrospectively identified. Time-indexed measurements of pBtO2, cerebral perfusion pressure (CPP), and intracranial pressure (ICP) were collected, and average values over 4-hour blocks were determined. Patients were stratified according to survival, and repeated measures analysis of variance was used to compare pBtO2, CPP, and ICP. The pBtO2 threshold most predictive for survival was determined. RESULTS: There were 8,759 time-indexed data points in 32 patients. The mean age was 39 years ± 16.5 years, injury severity score was 27.7 ± 10.7, and Glasgow Coma Scale score was 6.6 ± 3.4. Survival was 68%. Survivors consistently demonstrated higher pBtO2 values compared with nonsurvivors including age as a covariate (F = 12.898, p < 0.001). Individual pBtO2 was higher at the time points 8 hours, 12 hours, 20 hours to 44 hours, 52 hours to 60 hours, and 72 hours of monitoring (p < 0.05). There was no difference in ICP (F = 1.690, p = 0.204) and CPP (F = 0.764, p = 0.389) values between survivors and nonsurvivors including age as a covariate. Classification and regression tree analysis identified 29 mm Hg as the threshold at which pBtO2 was most predictive for mortality. CONCLUSION: The first 72 hours of pBtO2 neurologic monitoring predicts mortality. When the pBtO2 monitor remains below 29 mm Hg in the first 72 hours of monitoring, mortality is increased. This study challenges the brain oxygenation threshold of 20 mm Hg that has been used conventionally and delineates a time for monitoring pBtO2 that is predictive of outcome. LEVEL OF EVIDENCE: III, prognostic study.

Eastern association for the surgery of trauma: The open abdomen part III-A review of "Abdominal wall reconstruction"

Jose J. Diaz, Jr, MD, Daniel C. Cullinane, MD, Kosar A. Khwaja, MD, G. Hart Tyson, MD, Mickey Ott, MD, Rebecca Jerome, MLIS, MPH, Andrew J. Kerwin, MD, Bryan R. Collier, DO, Peter A. Pappas, MD, Ayodele T. Sangosanya, MD, John J. Como, MD, Faran Bokhari, MD, Elliott R. Haut, MD, Lou M. Smith, MD, Eleanor S. Winston, MD, Jaroslaw W. Bilaniuk, MD, Cynthia L. Talley, MD, Ronald Silverman, MD, and Martin A. Croce, MD, Baltimore, Maryland

Once bitten, twice incised: recurrent gallstone ileus

Uncommon causes of small bowel obstruction can provide interesting surgical decision-making challenges. This report describes a patient with recurrent gallstone ileus. According to most current reviews, erring on the side of enterolithotomy alone as the treatment of choice for gallstone ileus appears to be the most appropriate decision. Although a rare scenario, the situation of recurrent gallstone ileus presents an interesting learning opportunity. It is important to keep in mind the need for complete examination of the abdomen. Furthermore, evacuation of any remaining stones from the gallbladder is imperative if possible. Erring on the side of enterolithotomy alone as the treatment of choice for gallstone ileus has been shown to be a safe and effective treatment decision over a single-stage removal of the stone with closure of the cholecystoduodenostomy.

Initial results of a thoracic aortic endovascular program: safer in high-risk patients.

Results are presented from our single-institutional experience with thoracic endovascular aortic repair to confirm that it is safe in patients with significant comorbidities. A retrospective review of all patients undergoing endovascular or open thoracic aortic repair at our institution since 2002 was performed. Main outcome measures included clinical presentation, demographics, preoperative risk factors, operative details, and clinical outcomes. The endovascular group included 37 patients (22 males), whereas the open group included 19 patients (eight males). Eight patients per group were treated emergently for trauma or rupture (22% and 42%, respectively; p=0.11). Endovascular patients were significantly older with more comorbid conditions (p<0.05). However, the overall perioperative complication rate was similar in the two groups (32.4% and 31.6%, respectively). Postoperative renal failure occurred only in four open patients (21.1% vs. 0%, p < 0.05). Operative time, ventilator days, and total length of stay were also greater for open patients (p<0.05). There was one death in the endovascular group and three in the open group (2.7% and 15.8%, respectively; p=0.07). Endovascular patients had shorter operative time and length of stay, fewer ventilator days and intensive care unit days, and fewer transfusions. Although the endovascular patients were significantly older with more comorbidities, the complication rate was similar to the open group. Also, there was a trend toward lower mortality in the endovascular group (p=0.07). Endovascular repair is the procedure of choice for treating the descending thoracic aorta in high-risk patients even in the emergent setting.

Trimethoprim-Associated Hyperkalemia in a Young Trauma Victim

To the Editor: Trimethoprim-sulfamethoxazole (TMPS) is a commonly administered antimicrobial agent. Traditionally, this combination has been used for the treatment of urinary tract infection [1]; however, TMPS also is commonly used for prophylaxis against Pneumocystis jiroveci pneumonia in patients with human immunodeficiency virus (HIV) infection and in solid organ and stem cell recipients [2]. The agent also is the treatment of choice for some opportunistic infections other than Pneumocystis jiroveci and can be used against infections caused by Legionella spp., Toxoplasma gondii, Listeria monocytogenes, and Nocardia spp. Recently, the drug has been advocated as an excellent option for infections with community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) [3, 4]. Finally, TMPS can be used in the setting of nosocomial infections caused by Stenotrophomonas maltophilia and Acinetobacter spp. [5, 6]. Side effects of TMPS are attributable mostly to the sulfonamide component and include hepatotoxicity, nephrotoxicity, myelotoxicity, toxic epidermal necrolysis, and Stevens-Johnson syndrome, as well as many other less recognized complications [7, 8]. Less commonly, patients develop side effects attributable to trimethoprim, the most notable being hyperkalemia. Polyuria and hyperkalemia associated with trimethoprim are believed to originate from its being structurally related to amiloride, which has a potassium-sparing diuretic action [9-14]. We report the association of polyuria and severe hyperkalemia with TMPS use in a critically injured trauma victim. A 36-year old woman was involved in a motor vehicle crash and sustained severe closed head injury with frontal lobe intracerebral hemorrhage, multiple facial and skull fractures, as well as bilateral posterior arch fractures of C1 and an odontoid fracture. She had been taken by emergency medical services from the scene to an outside hospital, where she was intubated because of a Glasgow Coma Scale score (GCS) of nine. Thereafter, she was airlifted to our center. After initial stabilization, she underwent sequential operative repair of her facial and skull fractures and received clindamycin for perioperative prophylaxis. Her vertebral fractures were managed nonoperatively. She recovered slowly from her injuries but required both percutaneous tracheostomy and placement of a percutaneous endoscopic gastrostomy secondary to a persistently altered GCS, facial swelling, and a high-risk airway secondary to her cervical fractures. One week after admission, she developed pneumonia, which was treated empirically with doripenem, tobramycin, and vancomycin. She underwent bronchoalveolar lavage, and Stenotrophomonas maltophilia and Acinetobacter baumannii, both sensitive to TMPS, were isolated. Thus, TMPS was started at a dose of 224 mg q 6 h. Two days after initiation of TMPS therapy, the patient developed polyuria, and her serum potassium started to increase, peaking at 6.1 mg/dL (Fig. 1). Kayexalate and insulin were administered, and 40 mg of furosemide was given; however, the serum potassium concentration decreased only to 5.8 mg/dL. No evidence of myoglobinuria or compartment syndrome was present, and renal function (blood urea nitrogen/creatinine clearance) appeared normal. At this stage, TMPS was recognized as a potential cause of the hyperkalemia, the drug was stopped, and the serum potassium declined to 4.8 mg/dL. Her pneumonia had improved clinically, with improvement in her chest radiograph, temperature curve, white blood cell count, and PaO2:FIO2 (P:F) ratio. Additional doses of furosemide were given, and her serum potassium concentration normalized within 36 h. The patient’s further hospital course was uncomplicated, and she was discharged to a rehabilitation facility one week after the event. Development of hyperkalemia should be recognized as a potentially dangerous side effect of TMPS therapy [9-14]. Although this type of toxicity has been described most commonly as a consequence of high-dose intravenous TMPS, cases following oral therapy using low-dose TMPS also have been published [9, 11]. In one study, the incidence of this side effect was seven fold higher than with other antibiotics such as betalactams or fluoroquinolones [15]. Predisposing factors include renal failure, advanced age, use of angiotensin converting enzyme (ACE) inhibitors, and exposure to some drugs, such as spironolactone [15-17]. In the case presented here, hyperkalemia developed within 48 h after the start of drug exposure, which is earlier than in many published cases. However, numerous confounding treatments may contribute to a more rapid increase in potassium. Corticosteroids have been advocated to abrogate this specific side effect of trimethoprim, and fludrocortisone has been used as treatment of the condition

What Is a Complex Abdominal Wall

A complex abdominal wall refers to patient anatomy that falls out of the realm of a standard ventral hernia. This may include patients with a history of multiple hernia repairs, loss of abdominal domain with retraction of the abdominal fascia away from the midline, hernias with infected mesh, and those hernias associated with an enterocutaneous fistula or presence of an intestinal stoma. Abdominal reconstruction in these patients is complicated and is associated with significant morbidity and mortality. This chapter will discuss some of the predisposing factors to the development of a complex abdominal wall and a systematic approach to the care of these complex patients.