Delayed Presentation of Bowel Injury Associated with Pelvic Fragility Fracture in Patient with Bladder Sling: A Case Report.

CASE: An 85-year-old woman with a history of bladder mesh sling placement sustained a pelvic fracture and extraperitoneal bladder rupture after a ground-level fall. The patient underwent cystorrhaphy and percutaneous anterior column screw placement. Free air was identified on abdominal computed tomography scan on postoperative day 5. Exploratory laparotomy revealed a sigmoid colon perforation and extensive bowel adhesions to the anterior pelvis. CONCLUSION: This is the first report describing bowel injury and associated bladder rupture in a pelvic fragility fracture related to a prior bladder mesh sling. This case highlights the importance of obtaining a thorough surgical history when treating pelvic injuries.

Bicarbonate and Serum Lab Markers as Predictors of Mortality in the Trauma Patient.

Introduction: Severe trauma-induced blood loss can lead to metabolic acidosis, shock, and death. Identification of abnormalities in the bicarbonate and serum markers may be seen before frank changes in vital signs in the hemorrhaging trauma patient, allowing for earlier lifesaving interventions. In this study the author aimed to evaluate the usefulness of serum bicarbonate and other lab markers as predictors of mortality in trauma patients within 30 days after injury. Methods: This retrospective, propensity-matched cohort study used the TriNetX database, covering approximately 92 million patients from 55 healthcare organizations in the United States, including 3.8 million trauma patients in the last two decades. Trauma patients were included if they had lab measurements available the day of the event. The analysis focused on mortality within 30 days post-trauma in comparison to measured lab markers. Cohorts were formed based on ranges of bicarbonate, lactate, and base excess levels. Results: Before propensity score matching, a total of 1,275,363 trauma patients with same-day bicarbonate, lactate, or base excess labs were identified. A significant difference in mortality was found across various serum bicarbonate lab ranges compared to the standard range of 21-27 milliequivalents per liter (mEq/L), post-propensity score matching. The relative risk of death was 6.806 for bicarbonate ≤5 mEq/L; 8.651 for 6-10; 6.746 for 11-15; 2.822 for 16-20; and 1.015 for bicarbonate ≥28. Serum lactate also displayed significant mortality outcomes when compared to a normal level of ≤2 millimoles per liter. Base excess showed similar significant correlation at different values compared to a normal base excess of -2 to 2 mEq/L. Conclusion: This study, approximately 100 times larger than prior studies, associated lower bicarbonate levels with increased mortality in the trauma patient. While lactate and base excess offer prognostic value, lower bicarbonate values have a higher relative risk of death. The greater predictive value of bicarbonate and accessibility during resuscitations suggests that it may be the superior prognostic marker in trauma.

Remote Instruction in Focused Assessment With Sonography in Trauma (FAST) Exams for Surgery Residents: A Pilot Study.

BACKGROUND: The Focused Assessment with Sonography in Trauma (FAST) exam is an important component to the evaluation of trauma patients. With advances in technology and meeting limitations due to COVID-19, remote instruction and learning have gained popularity. We sought to determine whether remote instruction of FAST exams was feasible as sustainable surgical education and a possible alternative to traditional in-person teaching. METHODS: General surgery residents completed a baseline survey and skills assessment on FAST exams and were then randomized to remote or in-person instruction. The remote group participated in an instructional session with a content expert through video conference and then practiced on a simulated mannequin while the expert remotely provided feedback. The in-person group received the experience with the content expert in the room. Both groups completed a post-course survey immediately after the session and a follow-up survey and objective assessment at six-months. Results were compared with two-way analysis of variance (ANOVA). RESULTS: 14 residents underwent the curriculum, seven in each group. There was a significant increase in self-reported confidence when comparing pre- and immediate post-course results for both the remote and in-person groups. At six months, confidence scores remained elevated and skill assessment scores improved, although the latter did not reach significance. There was no significant difference in post-course results between the groups. CONCLUSIONS: Remote instruction of FAST exams was feasible. Pilot data demonstrated an increase in confidence and suggest outcomes that are similar to in-person instruction, which has positive implications for future remote educational and potentially clinical initiatives.

Pancreatic pseudocyst extending into psoas muscle mimicking acute complicated diverticulitis: A case report.

INTRODUCTION AND IMPORTANCE: Pancreatic pseudocysts (PP) are known sequelae of pancreatitis. In this case, we present a patient with a pancreatic pseudocyst extending to the left psoas muscle, initially masquerading as acute complicated diverticulitis. CASE PRESENTATION: A 43-year-old male with previous episode of pancreatitis presented with a one-week history of abdominal pain. Physical examination revealed left lower quadrant tenderness. A computed tomography (CT) showed a large intraperitoneal fluid collection extending to the left psoas muscle with segmental inflammation of the descending colon. The patient was managed medically with empiric antibiotic therapy for concern of complicated diverticulitis. Ultrasound-guided percutaneous drainage was performed and fluid analysis showed lipase >20,000 U/L. The patient was discharged home with the drain. At one month follow up a repeat CT showed resolution of the left psoas fluid collection. The drain was removed and the patient remained asymptomatic at two month follow-up. CLINICAL DISCUSSION: Pancreatic pseudocysts are well-known complications of pancreatitis. In this case, we describe extension of a pseudocyst to the left psoas muscle. We identified twelve previously reported patients diagnosed with PP involving the psoas muscles. Our case is unique as there is no previously published case in which a pseudocyst masqueraded as complicated diverticulitis. In analysis of the literature, most patients were managed with percutaneous drainage. Only 50% had documented complete resolution on follow up; of those 75% had undergone percutaneous drainage. CONCLUSION: Pancreatic pseudocysts that extend to the psoas muscle can mimic acute complicated diverticulitis upon presentation. These may be effectively managed with percutaneous drainage.