Impact of Staged Vascular Management on Limb Outcomes in Wartime Femoropopliteal Arterial Injury.

BACKGROUND: By necessity, wartime arterial injuries undergo staged management. Initial procedures may occur at a forward surgical team (role 2), where temporary shunts can be placed before transfer to a larger field hospital (role 3) for definitive reconstruction. Our objective was to evaluate the impact of staging femoropopliteal injury care on limb outcomes. METHODS: A military vascular injury database was queried for Iraq/Afghanistan casualties with femoropopliteal arterial injuries undergoing attempted reconstruction (2004-2012). Cases were grouped by initial arterial management: shunt placed at role 2 (R2SHUNT), reconstruction at role 2 (R2RECON), and initial management at role 3 (R3MGT). The primary outcome was limb salvage; secondary outcomes were limb-specific complications. Descriptive and intergroup comparative statistics were performed with significance defined at P ≤ 0.05. RESULTS: Of 257 cases, all but 4 had definitive reconstruction before evacuation to Germany (median, 2 days): 46 R2SHUNT, 84 R2RECON, and 127 R3MGT; median Mangled Extremity Severity Score was 6 for all groups. R2SHUNT had median extremity Abbreviated Injury Scale--vascular of 4 (other groups, 3; P < 0.05) and was more likely to have concomitant venous injury and to undergo fasciotomy. Shunts were used for 5 ± 3 hr. About 24% of R2RECON repairs were revised at role 3. Limb salvage rate of 80% was similar between groups, and 62% of amputations performed within 48 hr of injury. Rates of limb and composite graft complications were similar between groups. Thrombosis was more common in R2SHUNT (22%) than R2RECONST (6%) or R3MGT (12%) (P = 0.03). Late (>48 hr) thrombosis rates were similar, whereas 60% of R2SHUNT thromboses occurred on day of injury (P = 0.003 vs. 25% and 0%). CONCLUSIONS: Staged femoropopliteal injury care is associated with similar limb salvage to initial role 3 management. Early thrombosis is likely because of shunt failure but does not lead to limb loss. Current military practice guidelines are appropriate and may inform civilian vascular injury management protocols.

Biliary leak rates after cholecystectomy and intraoperative cholangiogram in surgical residency.

Postoperative bile leak (BL) after cholecystectomy is a rare but dreaded complication, and is felt to be increased during surgical training. We sought to determine the incidence of BL after selective intraoperative cholangiogram (IOC) at a teaching hospital and identify risk factors for predicting BLs. A retrospective review was performed analyzing all cholecystectomy with IOCs between September 2004 and September 2011. Residents performed under staff supervision. Of 1,799 cholecystectomies performed during the study period, only 96 (5.3%) were with IOCs (mean age 43, 65% female) and 4 BLs occurred (4.2%, 1 major duct injury, 3 cystic duct stump leaks). Univariate analysis demonstrated that male gender, significant medical comorbidities, case duration, preoperative endoscopic retrograde cholangiopancreatography, and surgery type (laparoscopic versus open) increased the patient's risk of BL; however, age, performance of secondary procedures, common bile duct exploration, resident level (PGY), and diagnosis did not increase BL risk. Multivariate regression revealed that only surgery type lead to an increased risk of BL (p = 0.001) (OR 31.61, 95% CI 3.96-252.18). Patient factors and PGY level did not significantly affect BL rates, although open and converted procedures were associated with higher rates, suggesting an increased risk of a BL with more complex cases.

Expediting return of bowel function after colorectal surgery.

BACKGROUND: Postoperative ileus is the main determinant of the length of hospital stay after colorectal surgery. Our objective was to analyze modifiable factors, including polyethylene glycol administration, associated with the return of bowel function. METHODS: A retrospective review of all patients who underwent elective open partial colectomy from 2004 to 2006 at a single institution. RESULTS: The time to the first bowel movement with and without oral intake within 48 hours postoperatively was 76 hours versus 134 hours (P < .001); with and without polyethylene glycol administration it was 73 hours versus 94 hours (P = .001); and with and without frequent ambulation it was 78 hours versus 95 hours (P = .012). With postoperative nasogastric tube drainage, the time to the first bowel movement was 22 hours longer (P = .002). CONCLUSIONS: These data confirm previous findings supporting no nasogastric tube drainage, early feeding, and frequent ambulation after colorectal surgery. Additionally, our data suggest a strong association (P = .001) between the use of polyethylene glycol and the early return of bowel function.

Clostridium difficile enteritis after colectomy.

Clostridium difficile infection of the colon is, unfortunately, a relatively common occurrence that typically follows treatment with antibiotics; however, C. difficile infection of the small bowel is a much more rare phenomenon with only 19 cases reported to date. We present three cases of isolated C. difficile enteritis after colectomy. Although all three patients were identified early and successfully treated with medical management without the need for surgical intervention, previous authors have suggested a much higher morbidity and mortality rate with this infection. This article reviews the current available literature on C. difficile enteritis to highlight this potentially serious condition in postoperative colectomy patients who present with low-grade fevers, abdominal or pelvic pain, and increased ileostomy output.