[Show abstract][Hide abstract] ABSTRACT: Background:
Percutaneous drainage is the standard treatment for perforated appendicitis with abscess. We studied factors associated with complete resolution (CR) with percutaneous drainage alone.
Ninety-eight patients underwent percutaneous drainage for acute appendicitis complicated by abscess (October 1990 to September 2010). CR was defined as clinical recovery, resolution of the abscess on imaging, and drain removal without recurrence. Patients achieving CR were compared with patients not achieving CR.
The rate of CR was 78.6% (n = 77). Abscess grade was the only radiological factor associated with CR (P = .007). The CR rate was higher with transgluteal drainage (90.9% vs 79.2%) than with other anatomic approaches (P = .018) and higher with computed tomography-guided drainage than with ultrasound-guided drainage (82.7% vs 64.3%, P = .046).
CR was more likely to be achieved in patients with lower abscess grade, computed tomography-guided drainage, and a transgluteal approach.
American journal of surgery 10/2015; DOI:10.1016/j.amjsurg.2015.07.017 · 2.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Gangrenous cholecystitis (GC) is difficult to diagnose preoperatively in the patient with suspected acute cholecystitis. We sought to characterize preoperative risk factors and post-operative complications.
Pathology reports of all patients undergoing cholecystectomy for suspected acute cholecystitis from June 2010 to January 2014 and admitted through the emergency department were examined. Patients with GC were compared with those with acute/chronic cholecystitis (AC/CC). Data collected included demographics, preoperative signs and symptoms, radiologic studies, operative details, and clinical outcomes.
Thirty-eight cases of GC were identified and compared with 171 cases of AC/CC. Compared with AC/CC, GC patients were more likely to be older (57 years vs. 41 years, p < 0.001), of male sex (63% vs. 31%, p < 0.001), hypertensive (47% vs. 22%, p = 0.002), hyperlipidemic (29% vs. 14%, p = 0.026), and diabetic (24% vs. 8%, p = 0.006). GC patients were more likely to have a fever (29% vs. 12%, p = 0.007) and less likely to have nausea/vomiting (61% vs. 80%, p = 0.019) or an impacted gallstone on ultrasound (US) (8% vs. 26%, p = 0.017). Otherwise, there was no significant difference in clinical or US findings. Among GC patients, US findings were absent (8%, n = 3) or minimal (42%, n = 16). Median time from emergency department registration to US (3.3 hours vs. 2.8 hours, p = 0.28) was similar, but US to operation was longer (41.2 hours vs. 18.4 hours, p < 0.001), conversion to open cholecystectomy was more common (37% vs. 10%, p < 0.001), and hospital stay was longer (median, 4 days vs. 2 days, p < 0.0001). Delay in surgical consultation occurred in 16% of GC patients compared with 1% of AC patients (p < 0.001).
Demographic features may be predictive of GC. Absent or minimal US signs occur in 50%, and delay in surgical consultation is common. Postoperative morbidity is greater for patients with GC compared with those with AC/CC.
Level of evidence:
Epidemiologic study, level III; therapeutic study, level IV.
[Show abstract][Hide abstract] ABSTRACT: Introduction: Distinguishing necrotizing from non-necrotizing soft tissue infections on the basis of clinical findings is challenging. None of the imaging modalities has been accepted as a gold standard for diagnosis. Our early experience has shown that IV contrast enhanced computed tomography (CT) can be very accurate in the diagnosis of necrotizing soft tissue infections (NSTI). In this study we explore the value of CT for NSTI over 5 years in our institution.
Methods: We retrospectively identified patients admitted to the Massachusetts General Hospital between July 1, 2009 and July 30, 2014, who received a CT for any of the following diagnoses: necrotizing fasciitis; NSTI; cellulitis; soft tissue abscess. Based on our prior findings,1 CT was considered positive for NSTI if: a) gas was identified in the soft tissues, b) multiple fluid collections were found (as opposed to a single collection, which was more consistent of pyomyositis), c) tissues were not enhanced by IV contrast, indicating necrosis, d) there were significant inflammatory changes under the fascia. The outcome measure was NSTI defined by the visual inspection of infected and necrotic soft tissue during surgical exploration. NSTI was considered absent if surgical exploration failed to identify any of these findings or the patient was successfully treated without surgical exploration.
Results: Of 150 patients that met study inclusion criteria, 51 underwent surgical exploration, and NSTI was confirmed in 14 (9%). The remaining 136 patients had either non-necrotizing infections during surgical exploration (n=37) or were treated non-operatively with successful resolution of their symptoms (n=99). The sensitivity of CT to identify NSTI was 86%, the specificity was 98%, the positive predictive value was 80%, and the negative predictive value was 99%. There were 3 patients with a positive CT result that did not have NSTI; they had either pyomyositis or a significant amount of pus that needed an operative management either way.
Conclusion: CT can reliably rule out NSTI. In the presence of a negative CT, the patient can be managed non-operatively under the assumption that there are no necrotizing elements in the infected soft tissues.
[Show abstract][Hide abstract] ABSTRACT: Background:
Ultrasound (US) is the first-line diagnostic study for evaluating gallstone disease and is considered the test of choice for diagnosing acute cholecystitis (AC). However, computed tomography (CT) is used widely for the evaluation of abdominal pain and is often obtained as a first abdominal imaging test, particularly in cases in which typical clinical signs of AC are absent or other possible diagnoses are being considered. We hypothesized that CT is more sensitive than US for diagnosing AC.
A prospective registry of all urgent cholecystectomies performed by our acute care surgery service between June 2008 and January 2014 was searched for cases of AC. The final diagnosis was based on operative findings and pathology. Patients were classified into two groups according to pre-operative radiographic work-up: US only or CT and US. The US group was compared with the CT and US group with respect to clinical and demographic characteristics. For patients undergoing both tests the sensitivity of the two tests was compared.
One hundred one patients with AC underwent both US and CT. Computed tomography was more sensitive than US for the diagnosis of AC (92% versus 79%, p = 0.015). Ultrasound was more sensitive than CT for identification of cholelithiasis (87% versus 60%, p < 0.01). Patients undergoing both tests prior to surgery were more likely to be older, male, have medical comorbidities, and lack typical clinical signs of AC.
Computed tomography is more sensitive than US for the diagnosis of AC and is most often used in patients without typical clinical signs of AC.
[Show abstract][Hide abstract] ABSTRACT: In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection
(CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.
World Journal of Emergency Surgery 08/2015; 10(1):38. DOI:10.1186/s13017-015-0033-6 · 1.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The value of additional imaging in clearing the cervical spine (C-spine) of alert trauma patients with tenderness on clinical exam and a negative computed tomographic (CT) scan is still unclear.
All adult trauma patients with a Glasgow Coma Scale of 15, C-spine tenderness in the absence of neurologic signs, and a negative C-spine CT were included. The study period extended from September 2011 to June 2012. C-spine CT scans were interpreted in detail and considered negative in the absence of any findings indicating bony, ligamentous, or soft tissue injury around the C-spine. The incidence of C-spine injury was evaluated using early (<24 h) repeat physical examination, MRI, and/or flexion-extension films.
Of 2015 patients with a C-spine CT, 383 (19 %) fulfilled the inclusion criteria. The median age was 43 (IQR: 30-53) and 44.7 % were female. Thirty-six patients (9.4 %) underwent MRI (3.7 %), flexion-extension imaging (5.2 %), or both (0.5 %), with no significant injuries identified and subsequent removal of the collar allowed. The remaining patients were clinically cleared within 24 h of presentation. None of the patients developed neurological signs following removal of the collar. On bivariate analysis, no variable except for evaluation by trauma surgery was associated with performance of additional imaging.
C-spine precautions can be withdrawn without additional imaging in most blunt trauma patients with C-spine tenderness but negative neurologic evaluation and C-spine CT. Focus should be placed on the detailed and comprehensive interpretation of the C-spine CT.
World Journal of Surgery 08/2015; 39(11). DOI:10.1007/s00268-015-3182-6 · 2.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Translation of evidence to practice regarding adherence to published guidelines for transfusion of red blood cells (RBCs) in critically ill patients is sometimes suboptimal. We sought to use a multimodal intervention founded on peer-to-peer feedback and monthly audit to increase adherence to restrictive RBC transfusion guidelines.
We conducted a prospective interventional study with a preintervention and postintervention comparison in our tertiary care center. For the 6-month preintervention period (January 1, 2013, to June 31, 2013) and the 6-month postintervention period (October 1, 2013, to March 31, 2014), all RBCs transfused in the surgical intensive care unit (SICU) were evaluated for pretransfusion hemoglobin (Hgb) trigger (TRIG). During the intervention, if stable low-risk patients were transfused outside of restrictive guidelines, the clinicians received e-mail notification and education from a surgeon colleague within 72 hours of transfusion. The mean TRIG, percentage of transfusions with TRIG greater than 8.0 g/dL, and rate of overtransfusion (posttransfusion Hgb > 10) were compared before and after intervention.
For stable, low-risk patients, mean TRIG decreased from 7.6 g/dL to 7.1 g/dL (p < 0.001) and percentage of transfusions with TRIG greater than 8.0 g/dL decreased from 25% to 2% (p < 0.001) The overtransfusion rate decreased from 11%to 3% (p = 0.001). Total 6-month transfusions decreased from 284 U to 181 U, a 36% decrease. There were no significant differences in median SICU or hospital lengths of stay. Although SICU discharge Hgb and hospital discharge Hgb were significantly lower in the intervention period (8.4 vs. 8.6 [p = 0.037] and 8.6 vs. 9.0 [p = 0.003]), 30-day readmission and mortality rates were similar.
A blood management program based on peer e-mail feedback was effective in improving adherence to guideline recommendations for transfusion of RBCs in stable, low-risk SICU patients.
Therapeutic/care management study, level IV.
[Show abstract][Hide abstract] ABSTRACT: On April 15, 2013, two improvised explosive devices (IEDs) exploded at the Boston Marathon and 264 patients were treated at 26 hospitals in the aftermath. Despite the extent of injuries sustained by victims, there was no subsequent mortality for those treated in hospitals. Leadership decisions and actions in major trauma centers were a critical factor in this response.
The objective of this investigation was to describe and characterize organizational dynamics and leadership themes immediately after the bombings by utilizing a novel structured sequential qualitative approach consisting of a focus group followed by subsequent detailed interviews and combined expert analysis.
Across physician leaders representing 7 hospitals, several leadership and management themes emerged from our analysis: communications and volunteer surges, flexibility, the challenge of technology, and command versus collaboration.
Disasters provide a distinctive context in which to study the robustness and resilience of response systems. Therefore, in the aftermath of a large-scale crisis, every effort should be invested in forming a coalition and collecting critical lessons so they can be shared and incorporated into best practices and preparations. Novel communication strategies, flexible leadership structures, and improved information systems will be necessary to reduce morbidity and mortality during future events. (Disaster Med Public Health Preparedness. 2015;0:1-7).
Disaster Medicine and Public Health Preparedness 06/2015; -1:1-7. DOI:10.1017/dmp.2015.42 · 0.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fulminant Clostridium difficile colitis (fCDC) is a highly lethal disease with mortality rates ranging between 12% and 80%. Although often these patients require a total abdominal colectomy (TAC) with ileostomy, there is no established management protocol for post-operative antibiotics. In this study we aim to make some recommendations for post-operative antibiotic usage, while describing the practice across different institutions.
Multi-institutional retrospective case series including fCDC patients who underwent a TAC between January 1, 2007, and June 30, 2012. We first analyzed the complete cohort and consecutively performed a survivor analysis, comparing different antibiotic regimens. Additionally we stratified by time interval (antibiotics for ≤7 d, or ≥8 d). Primary outcome was in-hospital mortality. Additional secondary outcomes included hospital length of stay (HLOS), ICU LOS, number of ventilator-free days, and occurrence of intra-abdominal complications (proctitis, abscess, sepsis, etc.).
A total of 100 fCDC patients that underwent a TAC were included across five institutions. Four different antibiotic regimens were compared; A (metronidazole IV+vancomycin PO), B (metronidazole IV), C (metronidazole IV+vanco PO and PR), and D (metronidazole IV+vancomycin PR). The combination of IV metronidazole with or without PO vancomycin showed superior outcomes in terms of a shorter ICU length of stay and more ventilator-free days. However, when comparing metronidazole alone vs. metronidazole and any combination of vancomycin, no significant differences were found. Neither the addition of vancomycin enema, nor the time interval changed outcomes.
Patients, after a TAC for fCDC, may be placed on either IV metronidazole or PO vancomycin depending upon local antibiograms, and proctitis may be treated with the addition of a vancomycin enema (PR). There was no data to support routine treatment of more than 7 d.