Perforated esophageal intervention focus (PERF) study: a multi-center examination of contemporary treatment.

The treatment of esophageal perforation (EP) remains a significant clinical challenge. While a number of investigators have previously documented efficient approaches, these were mostly single-center experiences reported prior to the introduction of newer technologies: specifically endoluminal stents. This study was designed to document contemporary practice in the diagnosis and management of EP at multiple institutions around the world and includes early clinical outcomes. A five-year (2009-2013) multicenter retrospective review of management and outcomes for patients with thoracic or abdominal esophageal perforation was conducted. Demographics, etiology, diagnostic modalities, treatments, subsequent early outcomes as well as morbidity and mortality were captured and analyzed. During the study period, 199 patients from 10 centers in the United States, Canada, and Europe were identified. Mechanisms of perforation included Boerhaave syndrome (60, 30.1%), iatrogenic injury (65, 32.6%), and penetrating trauma (25, 12.6%). Perforation was isolated to the thoracic segment alone in 124 (62.3%), with 62 (31.2%) involving the thoracoabdominal esophagus. Mean perforation length was 2.5 cm. Observation was selected as initial management in 65 (32.7%), with only two failures. Direct operative intervention was initial management in 65 patients (32.6%), while 29 (14.6%) underwent esophageal stent coverage. Compared to operative intervention, esophageal stent patients were significantly more likely to be older (61.3 vs. 48.3 years old, P < 0.001) and have sustained iatrogenic mechanisms of esophageal perforation (48.3% vs.15.4%). Secondary intervention requirement for patients with perforation was 33.7% overall (66). Complications included sepsis (56, 28.1%), pneumonia (34, 17.1%) and multi-organ failure (23, 11.6%). Overall mortality was 15.1% (30). In contemporary practice, diagnostic and management approaches to esophageal perforation vary widely. Despite the introduction of endoluminal strategies, it continues to carry a high risk of mortality, morbidity, and need for secondary intervention. A concerted multi-institutional, prospectively collected database is ideal for further investigation.

Traumatically injured Jehovah's Witnesses: a sixteen-year experience of treatment and transfusion dilemmas at a level I trauma center.

Traumatically injured Jehovah's Witnesses pose difficult management problems because of their refusal to accept blood transfusions. This retrospective review of all inpatient traumatically injured Jehovah's Witnesses at a level I trauma center over the past 16 years revealed 77 patients with 92% blunt and 8% penetrating injuries. The primary physician was aware of their unique religious status in only 32% of cases. Transfusion was performed in only 4 (5.2%) cases even though it was desired by the physician in 11 (14%) cases. One transfusion was performed against the patient's will. One minor was transfused using a court order. Two transfusions were performed in the trauma room before the patients' religious status was known. Major changes in therapeutic plans were made as a result of the patients' Jehovah's Witness status in 10 cases (13%). Early knowledge of the patient's religious status is essential to optimize patient care.

Clinical experience with three-in-one admixtures administered peripherally.

The purpose of this report was to describe the tolerance of hyperosmolar nutritionally complete solutions infused peripherally, as a bridge to enteral therapy in the surgical patient. Solutions providing approximately 40% of calories as carbohydrates were administered to 23 surgical patients with the fats, amino acids, and dextrose mixed in one container. Final osmolarity, when measured directly with additives, ranged from 1200-1350 mOsm/L. Approximately 85% of the patients had acceptable tolerance to this new technique. The patient tolerance of the high osmolar admixture in peripheral veins might be attributed to the buffering and dilution effect of the IV fats in combination with the higher pH of the amino acid solutions and the addition of heparin to the admixture. Strong support for this technique was voiced by experienced nutritional support physicians and hospital personnel for use in surgical patients who have immediate short-term needs.