Ronald F. Martin

Evolution in the management of traumatic diaphragmatic injuries: a multicenter review.

BACKGROUND Traumatic diaphragmatic injury (TDI) is uncommon and has historically been identified by chest x-ray and repaired by laparotomy with nonabsorbable suture. Blunt TDI was more frequently (90%) detected on the left. With advances in imaging and operative techniques, our objective was to evaluate evolution in incidence, location, and management of TDI. METHODS The medical records of patients admitted to three Wisconsin regional trauma centers with TDI from 1996 to 2011 were reviewed. Patients were stratified into blunt and penetrating injury and early (1996–2003) and recent (2004–2011) periods. p < 0.05 was significant. RESULTS A total of 454 patients was included, 87% were men. Median Injury Severity Score (ISS) was 22 and 19 in the early and recent periods, respectively. Diagnostic modality for TDI did not change over time when comparing chest x-ray, computed tomography, or intraoperative diagnosis for blunt (p = 0.214) or penetrating (p = 0.119) TDI. More right-sided penetrating TDI were identified in the recent versus early group (49% vs. 27%). Perihiatal injury was rare (2%). Minimally invasive repairs increased in the recent versus early group of penetrating TDI (5.8% vs. 0.9%, p = 0.040). Complex repairs (mesh, transposition) were required in only three patients. In-hospital mortality was 15% and 4% for blunt and penetrating TDIs, respectively (p < 0.001). CONCLUSION A large increase in the frequency of both blunt and penetrating TDIs in our region was documented. While no difference was observed regarding diagnosis of blunt TDI during the two study periods, our data show a change from historical reports; more injuries were detected by computed tomography. An increase in right-sided penetrating TDI was also observed. A small but previously unreported incidence of perihiatal/pericardial injury occurred with both blunt and penetrating TDIs. While the majority of injuries were repaired with laparotomy, minimally invasive repairs were used more frequently in the recent period. LEVEL OF EVIDENCE Epidemiologic study, level III. Therapeutic study, level IV.

Management of Burns

Not everybody will be diagnosed with cancer nor will everybody fracture a bone or develop a bowel obstruction, but almost everybody will suffer a burn one day. I was once taught that for every patient who is burned there is an element of adult behavioral failure (it was actually phrased differently). Certainly, some factors are well beyond our control: gas main explosions, deliberate violent acts, and other force majeure. However, a great deal of burns that people encounter are a direct result of loss of situational awareness. In the case of children who suffer burns, it is still usually an adult failure that leads to the injury. And burns are one of those consequences that is so devastating yet caused so quickly that it just takes a momentary lapse to yield sometimes horrific results. There is a reason the proverbial admonition states that we are playing with fire when we seek to do something dangerous. Our visceral apprehension regarding burns is well founded early in life as even small burns leave a distinct impression on most people who get them. Later in life, we develop a better abstract sense of how disabling and disfiguring burns can be. Of course, these beliefs are formed culturally over decades or even centuries of collective and individual experience. Books, movies, and other lore are based on the consequences of surviving major burns. This issue of the Surgical Clinics of North America, which is expertly crafted by Dr Sheridan and his colleagues, will provide the reader not only an opportunity to review what we have learned about the care of burn patients but also thoughts on goals and directions for future research. The ultimate goal, as suggested in the article by Drs Wolf, Tompkins, and Herndon, of no deaths, no scar, and no pain is an ambitious and laudable goal. In some respects, it is difficult to imagine how these goals can be met, but as the authors discuss, these are goals based on dealing with the consequences of mastering other problems that seemed impossibly challenging. Improvements in short-term survival and improvements in hospital care that allow these longer-term issues to exist have largely come along in our lifetime. So perhaps, their call to action is more akin to the Kennedy “moonshot.”

ForewordInflammatory Bowel Disease

Methods: Pooled patients (N=562) from two independent RCTs, with documented UC remission (revised Sutherland Disease Activity Index [DAI] subscores: rectal bleeding 0; mucosal appearance <2) were randomized 2:1 to receive MG 1.5 g qd (N=373) or placebo (N=189) for 6 months. Th e primary effi cacy endpoint was the proportion of patients who remained relapse-free aft er 6 months of treatment (relapse defi ned as a rectal bleeding subscore ≥1 and a mucosal appearance subscore ≥2 per DAI; UC fl are or UC symptoms leading to withdrawal; or initiated medication used to treat UC). Prognostic factors that may contribute to UC relapse include baseline demographics and disease characteristics such as age; sex; DAI total score, and subscores for stool frequency, mucosal appearance, physician’s assessment; time to last fl are; and disease duration. Covariate analysis was used to evaluate outcomes. Results: Demographics and baseline characteristics were similar between groups. Independent predictors of relapse included DAI score (p=0.0217), stool frequency subscore (p=0.0106), mucosal appearance score (p=0.0007), and physician’s global UC assessment score (p=0.0136). Aft er controlling for these prognostic factors in a multivariate analysis, the most infl uential prognostic factor for maintenance of remission was the DAI mucosal subscore (p=0.0032). Also, the eff ect of MG on maintenance of remission yielded a higher incidence of relapse-free patients versus placebo (odds ratio, 2.089; 95% CI, 1.407-3.103; p= 0.0003). Conclusion: MG dosed at 1.5 g once daily demonstrated a signifi cant protective eff ect for long-term maintenance of remission of UC during the 6-month treatment period aft er controlling for prognostic factors. Th e most infl uential prognostic factor was the mucosal score at baseline. Even in the presence of signifi cant, competing, prognostic factors, MG signifi cantly increased the incidence of relapse-free patients versus placebo. Disclosure: Lichtenstein Salix: consultant, grant/research; Gordon Salix: consultant; Zakko Salix: grant support, Novartis, Takeda, Biogen: Advisory board, consultant; Murthy: none; Sedghi: Salix speaker bureau; Pruitt: none; Yuan Salix: employee; Merchant Salix: employee; Shaw Salix: employee. Th is research was supported by an industry grant from Salix Pharmaceuticals, Inc.

Caring for Geriatric Surgical Patients

From the time the Sumerian civilization began to form during the Uruk period, approximately four millennia BCE until fairly recently, the most medicine had to offer people to keep them alive and postpone death was not very much. Some people lived to become very old; some died very young, and most died earlier than they do in the present day. The probability curve for longevity of life was more centered. Fast forward six thousand years, give or take, and we have developed an understanding of human anatomy, general anesthesia, the germ theory, antibiotics, organized medical training programs, cardiopulmonary bypass, the ability to ventilate and oxygenate via endotracheal means outside of an operating room, hemodialysis, solid organ transplantation, implantable hardware for repair of fractures and joint replacement, artificial heart valves, central venous access, total parenteral nutrition, new antibiotics to deal with organisms resistant to the old antibiotics, vasoactive agents, implantable cardioverter-defibrillators, and a whole host of other devices, drugs, procedures, and imaging devices. Yet, despite our profound advances in knowledge and technological sophistication, we did not necessarily develop the wisdom to know why we developed it or when not to use it. Until the 1950s or 1960s, when someone told a doctor, “Do whatever you can, Doc,” it was a pretty limited request, albeit not recognized as such. Today, the same request has very few limitations. There is certainly marked disparity between countries and cultures about how much health care is available, expected, or provided. There are clear differences in how people allocate and pay for health care. Nonetheless, one thing holds true across all types of health care systems: the better you get at dealing with problems that end life prematurely, the larger number of elderly people you get.

Acute Care Surgery

The full spectrum of Acute Care Surgery is expertly addressed, with each chapter highlighting cutting-edge advances in the field and underscoring state-of-the-art management paradigms. In an effort to create the most definitive reference on Acute Care Surgery, an evidence-based approach is emphasized for all content included. Also, notable controversies are discussed in detail often accompanied by data-driven resolutions.

Vascular Surgery and Endovascular Therapy

This is an important review on vascular surgery for the general surgeon. Topics include work up, optimal medical management, non-atherosclerotic arterial diseases, claudication, critical limb ischemia, aneurismal diseases, mesenteric ischemia, vascular trauma, venous diseases, thromboembolic diseases, dialysis access, carotid artery occlusive disease, and more!

Current topics in transplantation.

There comes a time in many surgeons’ careers where the demands of running the business of patient care becomes more challenging than the actual caring for the patients. I suspect it is inevitable that we should all develop in such a way that performing our daily tasks of diagnosing and treating the sick becomes easier and perhaps even comfortable. After all, although our understanding of how humans medically function or fail to—and what we can do to prevent or alter that—evolves apace, the rate of change of medical knowledge pales in comparison to the pace of change for the society in which we provide the care. One stroke of a pen or even the threat of a penstroke in Washington, DC can set our entire workplace on its ear. For the past several years, I have had the privilege of being part of a small group of doctors who are responsible for running our fairly good-sized organization. During that time we had the market collapse of 2008, the persistent effect of two lingering armed conflicts in Asia, a significant decline in the manufacturing economy (which greatly affected our local patient population), somewhat polarized transitions of both state and federal executive administrations and legislative branches, and a host of other “nonmedical” frame shifts with which to contend. However, none of those features has seemed all that onerous to work around or with from my standpoint. Change is always the nature of the game. What I do find particularly challenging is one somewhat related concept: the shift from volume-based care to value-based care and how to get doctors to buy into it. At its core, value-based care and volume-based care should not even be a transition—should it? If we were always doing thing for patients as opposed to doing things to patients, we would always be providing value-based care. We would always be considering the health risk and benefit consequences of all clinical decisions in the context of the affordability and effectiveness of the care for the patient. And if we really thought and acted this way—in an ideal world—value-based care would be all that we would deliver. But we don’t practice that way. Intentionally or unintentionally, we

Multidisciplinary breast management.

I began as Consulting Editor for the Surgical Clinics of North America a number of years ago with 2 basic goals: first, to help produce a series of publications that covered topics of interest and necessity to general surgeons, and second, to try to explore what a general surgeon really is. It doesn’t take a grammarian or logician to realize that those 2 goals are either so intertwined as to be one or tautologically impossible. After all, in order to know what matters to a general surgeon, one should probably understand what a general surgeon does. I shall leave it to the readership to decide if the content provided has been useful. As to what constitutes a general surgeon— that, I am still trying to decide. The American Board of Surgery (ABS), according to its Booklet of Information, requires residency “experience” in 10 areas of surgery, including Alimentary Tract (including Bariatric Surgery); Abdomen and its

Contemporary Management of Esophageal Malignancy

I sometimes wonder how effectively we in medicine disseminate information. Usually, when I wonder this it has been prompted by some strained incredulity on my part that something that I thought should be commonly held knowledge is not. To be fair, I have no idea how many times in a day or month or year someone else feels similarly about my gaps in knowledge. It might even bruise my ego a bit to find out. Feelings put aside though, there remains a fundamental problem with how we disseminate, or fail to disseminate, information. The Surgical Clinics of North America has long been a resource for compiled information for nearly a century now. I have had the privilege of serving as its Consulting Editor since 2004. One of the first issues distributed during my tenure was an issue on esophageal surgery. This current volume is on the same topic but with a slightly different perspective. A great deal of progress has been made since we published the prior issue in 2005 and that progress is excellently captured by Drs Denlinger and Reed and their colleagues. I am optimistic that this volume will serve as a valuable resource for surgeons and other physicians alike. What concerns me though is that some of the information from even the previous volume is still not among the common working knowledge of many. I suspect there are a multitude of reasons for this: continued specialization to a very narrow range of practice, a generalized increase in desire for “just-in-time” information, a decreased sense of ownership of some patient problems by some physicians, and perhaps a general sense that the information torrent is just too overwhelming to absorb. While I happen to believe that most of those reasons are closer to excuses than explanations, I would bet that I am in the minority opinion on that score. The reality appears to be that we have fractured health care into discordant elements and there are very few physicians left who feel compelled to desire a comprehensive base set of knowledge. The team approach to medical care has allowed for many to perform a narrow function in the hopes that another team member either

Recent Advances and Future Directions in Trauma Care

Dr. Lynn finished his Medical School at the Federal University of Rio de Janeiro, Brazil. He trained in General Surgery at Tel Aviv University/Sheba Medical Center in Israel and did a Trauma Critical Care fellowship at the Ryder Trauma Center in Miami, Florida. Dr. Lynn is a retired Lieutenant Colonel from the Israeli Military where he served for 18 years. His main positions were as Flight Surgeon with the Israeli Air Force Special Forces, Medical Director of the Israeli Air Rescue and Medical Evacuation Unit and Chief of Trauma for the Israeli Military. Dr. Lynn was the Medical Commander of Operation Solomon, the largest airborne humanitarian mission in history. He was the Commander of the Israeli medical team deployed to Nairobi, for the bombings of the American embassy and Team commander and chief surgeon of 2 Israeli field hospitals deployed to Turkey in the aftermath of the1999 earthquakes. As Chief of Trauma and working at the Surgeon General Headquarters, Dr. Lynn was in charge of policy making for field trauma care for the military, consultant for the civilian Emergency Medical Services and in charge of disaster preparedness of all Israeli hospitals, working in conjunction with the Ministry of Health.