Umbilical Fascial Defects are Common and Predict Trocar Site Hernias After Laparoscopic Appendectomy.

INTRODUCTION: Investigations have demonstrated that trocar site hernia (TSH) is an under-appreciated complication of laparoscopic surgery, occurring in as many as 31%. We determined the incidence of fascial defects prior to laparoscopic appendectomy and its impact relative to other risk factors upon the development of TSH. METHODS: TSH was defined as a fascial separation of ≥ 1 cm in the abdominal wall umbilical region on abdominal computerized tomography scan (CT) following laparoscopic appendectomy. Patients admitted to our medical center who had both a preoperative CT and postoperative CT for any reason (greater than 30 days after surgery) were reviewed for the presence of TSH from May 2010 to December 2018. CT scans were measured for fascial defects, while investigators were blinded to film timing (preoperative or postoperative) and patient identity. Demographic information was collected. RESULTS: 241 patients undergoing laparoscopic appendectomy had both preoperative and late postoperative CT. TSH was identified in 49 (20.3%) patients. Mean preoperative fascial gap was 3.3 ± 4.3 mm in those not developing a postoperative hernia versus 14.8 ± 7.3 mm in those with a postoperative hernia (P < .0001). Preoperative fascial defect on CT was predictive of TSH (P < .001, OR = 1.44), with an Area Under the Curve (AUC) of .921 (95%CI: .88-.92). Other major risk factors for TSH were: age greater than 59 years (P < .031, OR = 2.48); and obesity, BMI > 30 (P < .012, OR = 2.14). CONCLUSIONS: The incidence of trocar site hernia was one in five following laparoscopic appendectomy. The presence of a pre-existing fascial defect, advanced age, and obesity were strong predictors for the development of trocar site hernia.

Appendiceal Endometriosis Presenting as Possible Cecal Mass.

BACKGROUND: Endometriosis is endometrial tissue located outside of the uterus. Endometriosis is rarely found in the appendix and can present very similar to acute appendicitis and is often indistinguishable on physical exam and imaging. The diagnosis is typically made after an appendectomy on pathology. CASE SUMMARY: A 45-year-old female presented with right sided abdominal pain and CT revealed a possible cecal or appendiceal lesion. Colonoscopy revealed a submucosal non-obstructing cecal mass. In the operating room, the appendix was completely adherent to the cecum and a laparoscopic ileocecectomy was performed. Pathology revealed endometriosis of the appendix and cecum. DISCUSSION: Endometriosis of the appendix is a rare condition reported in less than 1% of females that is diagnosed after an appendectomy is performed for suspected appendicitis or other pathology. This diagnosis is made based on the finding of endometrial glands and stroma in the appendix. This can present as acute appendicitis or appendiceal or peri-appendiceal mass on imaging. When symptomatic, pain can align with the menstrual cycle and hemoperitoneum may be encountered intra-operatively. Treatment can be appendectomy, ileocecectomy, or right hemicolectomy if malignancy is suspected. In the patient we described, an ileocecectomy was performed with the intention of converting to a right hemicolectomy if the frozen section pathology had revealed malignancy. This case illustrates the importance of having a broad differential when diagnosing patients with abdominal pain, especially in women of childbearing age. CONCLUSION: Appendiceal endometriosis should be considered in females of childbearing age with abdominal pain or cecal/appendiceal mass on imaging.

Putting a halt to unnecessary transfers: Do patients with isolated subarachnoid hemorrhage and Glasgow Coma Scale of 13 to 15 need a trauma center?

OBJECTIVES: Trauma patients with isolated subarachnoid hemorrhage (iSAH) presenting to nontrauma centers are typically transferred to an institution with neurosurgical availability. However, recent studies suggest that iSAH is a benign clinical entity with an excellent prognosis. This investigation aims to evaluate the neurosurgical outcomes of traumatic iSAH with Glasgow Coma Scale (GCS) of 13 to 15 who were transferred to a higher level of care. METHODS: The American College of Surgeon Trauma Quality Improvement Program was retrospectively analyzed from 2010 to 2015 for transferred patients 16 years and older with blunt trauma, iSAH, and GCS of 13 or greater. Those with any other body region Abbreviated Injury Scale of 3 or greater, positive or unknown alcohol/drug status, and requiring mechanical ventilation were excluded. The primary outcome was need for neurosurgical intervention (i.e., intracranial monitor or craniotomy/craniectomy). RESULTS: A total of 11,380 patients with blunt trauma, iSAH, and GCS of 13 to 15 were transferred to an American College of Surgeon level I/II from 2010 to 2015. These patients were 65 years and older (median, 72 [interquartile range (IQR), 59-81]) and white (83%) and had one or more comorbidities (72%). Eighteen percent reported a bleeding diathesis/chronic anticoagulation on admission. Most patients had fallen (80%), had a GCS of 15 (84%), and were mildly injured (median Injury Severity Score, 9 [IQR, 5-14]). Only 1.7% required neurosurgical intervention with 55% of patients being admitted to the intensive care unit for a median of 2 days (IQR, 1-3 days). Furthermore, 2.2% of the patients died. The median hospital length of stay was only 3 days (IQR, 2-5 days), and the most common discharge location was home with self-care (62%). Patient factors favoring neurosurgical intervention included high Injury Severity Score, low GCS, and chronic anticoagulation. CONCLUSION: Trauma patients transferred for iSAH with GCS of 13 to 15 are at very low risk for requiring neurosurgical intervention. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

Stop flailing: The impact of bicortically displaced rib fractures on pulmonary outcomes in patients with chest trauma - an American Association for the Surgery of Trauma multi-institutional study.

BACKGROUND: Current evaluation of rib fractures focuses almost exclusively on flail chest with little attention on bicortically displaced fractures. Chest trauma that is severe enough to cause fractures leads to worse outcomes. An association between bicortically displaced rib fractures and pulmonary outcomes would potentially change patient care in the setting of trauma. We tested the hypothesis that bicortically displaced fractures were an important clinical marker for pulmonary outcomes in patients with nonflail rib fractures. METHODS: This nine-center American Association for the Surgery of Trauma multi-institutional study analyzed adults with two or more rib fractures. Admission computerized tomography scans were independently reviewed. The location, degree of rib fractures, and pulmonary contusions were categorized. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of pneumonia, acute respiratory distress syndrome (ARDS), and tracheostomy. Analyses were performed in nonflail patients and also while controlling for flail chest to determine if bicortically displaced fractures were independently associated with outcomes. RESULTS: Of the 1,110 patients, 103 (9.3%) developed pneumonia, 78 (7.0%) required tracheostomy, and 30 (2.7%) developed ARDS. Bicortically displaced fractures were present in 277 (25%) of patients and in 206 (20.3%) of patients without flail chest. After adjusting for patient demographics, injury, and admission physiology, negative pulmonary outcomes occurred over twice as frequently in those with bicortically displaced fractures without flail chest (n = 206) when compared with those without bicortically displaced fractures-pneumonia (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-3.6), ARDS (OR, 2.6; 95% CI, 1.0-6.8), and tracheostomy (OR, 2.7; 95% CI, 1.4-5.2). When adjusting for the presence of flail chest, bicortically displaced fractures remained an independent predictor of pneumonia, tracheostomy, and ARDS. CONCLUSION: Patients with bicortically displaced rib fractures are more likely to develop pneumonia, ARDS, and need for tracheostomy even when controlling for flail chest. Future studies should investigate the utility of flail chest management algorithms in patients with bicortically displaced fractures. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

Percutaneous Cholecystostomy Tube Leading to a "Floating" Gallbladder: A Case Report.

In patients with significant comorbid conditions, acute cholecystitis is managed through surgical intervention or with cholecystostomy tube placement (CTP). The literature is not definitive in its recommendations for cholecystectomy versus cholecystostomy. This case report describes a presentation of acute calculous cholecystitis managed with CTP. Over a 10-week period, due to complications with the tube, the decision was made to perform a cholecystectomy. Upon open surgical exploration, an atraumatic, ruptured, and chronically inflamed gallbladder was found without attachment to the subhepatic plate and, in essence, free "floating" in the peritoneum. To our knowledge, this is the first-known documented case report in the English medical literature. An elderly woman, with significant co-morbidities, following two months of antibiotic treatment for acute cholecystitis and subsequent percutaneous cholecystostomy tube placement and re-placements, underwent elective laparoscopic cholecystectomy, which was converted to open surgery. Upon exploration, a detached, "floating" gallbladder was found posterior to the transverse colon and removed after lysing extensive peritoneal adhesions. Subsequent to the cholecystectomy, the patient had uncomplicated recovery. The literature does not present a clear consensus on CTP use vs early cholecystectomy in high-risk patients with acute cholecystitis. This management decision is based primarily on the surgeon's clinical judgment and the use of evidence-based risk assessment indices. The "floating gallbladder" is a rare, benign complication that affirms the importance of extensively assessing the risks and benefits of CTP as compared to cholecystectomy in the elderly and/or comorbid patient.

Can acute care surgeons perform while fatigued? An EAST multicenter study.

BACKGROUND: Fatigued surgeon performance has only been assessed in simulated sessions or retrospectively after a night on call. We hypothesized that objectively assessed fatigue of acute care surgeons affects patient outcome. METHODS: Five acute care surgery services prospectively identified emergency cases over 27 months. Emergency cases were defined by the surgeon identifying the patient as requiring immediate operation upon consultation or admission. Within 48 hours, surgeons reported sleep time accumulated before operation, if nonclinical delays to operation occurred, and patient volume during the shift. To maximize differences, fatigued surgeons were defined as performing a case after midnight without having slept in the prior 18 hours. Rested surgeons performed cases at or before 8 PM or after at least 3 hours of sleep before operation. A four-level ordinal scale was used to assign case complexity. Hierarchical logistic regression models were constructed to assess the impact of fatigue on mortality and major morbidity while controlling for center and patient level factors. RESULTS: Of 882 cases collected, 611 met criteria for fatigue or rested. Of these cases, 370 were performed at night and 182 by a fatigued surgeon. Rested surgeons were more likely to be operating on an older or female patient; other characteristics were similar. Mortality and major morbidity were similar between fatigued and rested surgeons (12.1% vs 12.1% and 46.9% vs 48.9%), respectively. After controlling for center and patient factors, surgeon fatigue did not affect mortality or major morbidity. Mortality variance was 6.30% and morbidity variance was 7.02% among centers. CONCLUSION: Acute care surgeons have similar outcomes in a fatigued or rested state. Work schedules for acute care surgeons should not be adjusted to shifts less than 24 hours for the sole purpose of improving patient outcomes. LEVEL OF EVIDENCE: Prognostic study, level IV.

Trauma/hemorrhagic shock mesenteric lymph upregulates adhesion molecule expression and IL-6 production in human umbilical vein endothelial cells.

Trauma/hemorrhagic shock (T/HS) is associated with significant lung injury, which is mainly due to an inflammatory process, resulting from the local activation and subsequent interaction of endothelial cells and leukocytes. Adhesion molecules expressed by both cell types play a crucial role in the process of neutrophil-mediated endothelial cell injury. We have previously shown that mesenteric lymph duct ligation prevents T/HS-induced lung leukocyte infiltration and endothelial injury, suggesting that inflammatory factors originating from the gut and carried in the lymph are responsible for the lung injury observed following T/HS. Based on these observations, we hypothesized that inflammatory substances in T/HS lymph trigger lung injury by a mechanism involving the upregulation of adhesion molecules. To test this hypothesis, we examined whether T/HS mesenteric lymph induces the expression of E-selectin, P-selectin, and intracellular adhesion molecule-1 (ICAM-1) in human umbilical vein endothelial cells (HUVECs). Furthermore, because the cytokine IL-6 is an important component of the endothelial inflammatory process, we investigated how T/HS lymph affects the production of IL-6 by HUVECs. Mesenteric lymph from T/HS rats increased both E- and P-selectin, as well as ICAM-1 expression on HUVECS, as compared to trauma/sham shock (T/SS) lymph or medium only groups. However, T/HS lymph failed to induce the shedding of E-selectin. In HUVECs treated with T/HS lymph, IL-6 concentrations were higher than HUVECs treated with T/SS lymph. These findings suggest that mesenteric lymph produced after hemorrhagic shock potentiates lung injury by the upregulation of endothelial cell adhesion molecule expression and IL-6 production.

The role of oxidant-mediated pathways in the cytotoxicity of endothelial cells exposed to mesenteric lymph from rats subjected to trauma-hemorrhagic shock.

Because gut-derived factors carried in mesenteric lymph are implicated in multiple organ dysfunction syndrome and have been shown to injure endothelial cells, we investigated several cellular pathways by which this process could occur. To accomplish this, mesenteric lymph (5%, v/v) collected at 1 to 3 h postshock from male rats undergoing trauma (5-cm laparotomy) and hemorrhagic shock (90 min of mean arterial pressure [MAP] of 30 mmHg; T/HS) was tested for endothelial cell cytotoxicity on human umbilical vein endothelial cells (HUVECs). Over 30 pharmacologic agents that had been reported to inhibit endothelial cell death were tested for their ability to prevent T/HS lymph-induced HUVEC cell death. These included agents documented to protect against oxidant-mediated, calcium-mediated, and arachidonic acid pathway-mediated endothelial cell injury and death. These pharmacologic inhibitors were preincubated with HUVECs for 1 h or were added to the HUVECs simultaneously with lymph, and were then incubated for 18 h. Controls were lymph alone, inhibitor alone, or medium alone. Mitochondrial tetrazolium (MTT) and LDH release assays were used to determine cell viability. The inhibitors that significantly protected HUVECs from the cytotoxicity of T/HS lymph (P < 0.001) included the antioxidant combination of vitamins C and E and the antioxidant-lipooxygenase inhibitor nordihydroguaretic acid (NDGA). These agents were equally effective when added simultaneously with lymph or preincubated with the HUVECs, suggesting an extracellular or membrane-bound process. In summary, the inhibitors that provided protection from toxic lymph appear to work at the membrane and are involved in limiting membrane peroxidation. Based on this study, it appears that an oxidant pathway is involved in T/HS lymph-induced endothelial cell injury and death.

Multicenter review of diaphragm pacing in spinal cord injury: successful not only in weaning from ventilators but also in bridging to independent respiration.

BACKGROUND: Ventilator-dependent spinal cord-injured (SCI) patients require significant resources related to ventilator dependence. Diaphragm pacing (DP) has been shown to successfully replace mechanical ventilators for chronic ventilator-dependent tetraplegics. Early use of DP following SCI has not been described. Here, we report our multicenter review experience with the use of DP in the initial hospitalization after SCI. METHODS: Under institutional review board approval for humanitarian use device, we retrospectively reviewed our multicenter nonrandomized interventional protocol of laparoscopic diaphragm motor point mapping with electrode implantation and subsequent diaphragm conditioning and ventilator weaning. RESULTS: Twenty-nine patients with an average age of 31 years (range, 17-65 years) with only two females were identified. Mechanism of injury included motor vehicle collision (7), diving (6), gunshot wounds (4), falls (4), athletic injuries (3), bicycle collision (2), heavy object falling on spine (2), and motorcycle collision (1). Elapsed time from injury to surgery was 40 days (range, 3-112 days). Seven (24%) of the 29 patients who were evaluated for the DP placement had nonstimulatable diaphragms from either phrenic nerve damage or infarction of the involved phrenic motor neurons and were not implanted. Of the stimulatable patients undergoing DP, 72% (16 of 22) were completely free of ventilator support in an average of 10.2 days. For the remaining six DP patients, two had delayed weans of 180 days, three had partial weans using DP at times during the day, and one patient successfully implanted went to a long-term acute care hospital and subsequently had life-prolonging measures withdrawn. Eight patients (36%) had complete recovery of respiration, and DP wires were removed. CONCLUSION: Early laparoscopic diaphragm mapping and DP implantation can successfully wean traumatic cervical SCI patients from ventilator support. Early laparoscopic mapping is also diagnostic in that a nonstimulatable diaphragm is a convincing evidence of an inability to wean from ventilator support, and long-term ventilator management can be immediately instituted. LEVEL OF EVIDENCE: Therapeutic study, level V.

Intensive care unit management of the trauma patient.

OBJECTIVE: The goal of this concise review is to provide an overview of some of the most important intensive care unit issues and approaches that are unique to trauma patients as compared with the general intensive care unit population. STUDY SELECTION: Clinical trials in trauma patients focusing on hemorrhage control, issues in resuscitation, staged operative repair of multiple injuries, the diagnosis and therapy of the abdominal compartment syndrome, and the treatment of traumatic brain injury were identified on PubMed. CONCLUSIONS: The intensive care unit care of the trauma patient differs from that of other intensive care unit patients in many ways, one of the most important being the need to continuously integrate operative and nonoperative therapy. Although progress in the care of the injured has been made, death due to uncontrolled bleeding, severe head injury, or the development of multiple organ dysfunction syndrome remains all too common in this patient population. Furthermore, due to the potential nature of the injuries, the conundrum not infrequently arises that the optimal treatment for one injury or organ system, such as preoperative permissive hypotension in actively bleeding patients, may result in suboptimal or even deleterious therapy in the presence of another injury, such as traumatic brain injury. LEARNING OBJECTIVES: On completion of this article, the reader should be able to:Dr. Deitch has disclosed that he is/was the recipient of grant/research funds from Celgene. Dr. Dayal has disclosed that she has no financial relationships with or interests in any commercial companies pertaining to this educational activity. Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity. Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.

Shock mesenteric lymph-induced rat polymorphonuclear neutrophil activation and endothelial cell injury is mediated by aqueous factors.

BACKGROUND: After trauma and hemorrhagic shock (T/HS), mesenteric lymph (ML) activates polymorphonuclear neutrophils (PMNs), injures endothelial cells (ECs), and predisposes to lung injury. The involved mediators, however, are unknown. We studied the ability of aqueous (AQ) and lipid (LIP) extracts of rat T/HS ML to activate PMNs and injure ECs. METHODS: ML was collected from male rats undergoing trauma (laparotomy) plus hemorrhagic shock (30 mm Hg, 90 minutes) or sham shock. AQ and LIP ML fractions were separated using the Bligh-Dyer technique. Human umbilical vein endothelial cells were incubated 18 hours in 5% LIP or AQ lymph fractions and viability was assessed using the MTT assay. Rat PMNs incubated 5 minutes with 3% LIP or AQ fractions were assessed for respiratory burst (RB) and cytosolic calcium ([Ca(2+)](i)) using dihydrorhodamine 123 and fura-2AM. Human PMN responses to AQ and LIP T/HS lymph were studied similarly. RESULTS: EC incubated in AQ showed 19 +/- 4% viability as compared with 65 +/- 11% in LIP (p < 0.001). Whole lymph affected ECs comparably to AQ T/HS lymph. Rat PMN basal [Ca(2+)](i) increased after exposure to AQ but not LIP T/HS lymph extracts. AQ T/HS lymph primed [Ca(2+)](i) responses to macrophage inflammatory protein-2 and platelet-activating factor; neither LIP T/HS nor any trauma and sham shock lymph fraction caused PMN priming. Rat PMN RB was elevated after AQ T/HS lymph incubation when compared with buffer (610 +/- 122 U/s vs. 225 +/- 38 U/s, p = 0.01). Rat PMN incubation in LIP T/HS lymph caused minimal activation (289 +/- 28 U/s, p = NS). Conversely, human PMN showed [Ca(2+)](i) and RB priming by rat T/HS LIP and not AQ extracts. CONCLUSION: T/HS mesenteric lymph contains multiple biologically active mediators. Both AQ and LIP extracts of T/HS lymph are toxic to human umbilical vein endothelial cells, with AQ more active than LIP. Only AQ T/HS lymph activates rat PMNs, although LIP rat lymph extract activates human PMNs. These findings demonstrate the complex nature of gut lymph-derived biologic factors as well as species-specific differences on PMN and EC physiology. Therapies directed at any one specific molecule or mediator are therefore unlikely to be successful.