Using a Bedside Video-assisted Test Tube Test to Assess Stoma Viability: A Report of 4 Cases.

Mucosal discoloration of an intestinal stoma may indicate self-limited venous congestion or necrosis necessitating operative revision. A common bedside technique to assess stoma viability is the "test tube test". A clear tube is inserted into the stoma and a hand-held light is used to assess the color of the stoma. A technique (video-assisted test tube test [VATTT]) developed by the authors utilizes a standard video bronchoscope inserted into a clear plastic blood collection tube to visually inspect and assess the mucosa. This technique was evaluated in 4 patients (age range 49-72 years, all critically ill) with a discolored stoma after emergency surgery. In each case, physical exam revealed ischemic mucosa at the surface either immediately after surgery or after worsening hypotension weeks later. Serial test tube test assessments were ambiguous when trying to assess deeper mucosa. The VATTT assessment showed viable pink mucosa beneath the surface and until the fascia was revealed in 3 patients. One (1) patient had mucosal ischemia down to the fascia, which prompted operative revision of the stoma. The new stoma was assessed with a VATTT and was viable for the entire length of the stoma. VATTT provided an enhanced, magnified, and clearer way to visually assess stoma viability in the postoperative period that can be performed at the bedside with no adverse events. It may prevent unnecessary relaparotomy or enable earlier diagnosis of deep ostomy necrosis. Validity and reliability studies are warranted.

Increased ICU resource needs for an academic emergency general surgery service*.

OBJECTIVE: ICU needs of nontrauma emergency general surgery patients are poorly described. This study was designed to compare ICU utilization of emergency general surgery patients admitted to an acute care emergency surgery service with other general surgery patients. Our hypothesis is that tertiary care emergency general surgery patients utilize more ICU resources than other general surgical patients. DESIGN: Retrospective database review. SETTING: Academic, tertiary care, nontrauma surgical ICU. PATIENTS: All patients admitted to the surgical ICU over age 18 between March 2004 and June 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Six thousand ninety-eight patients were evaluated: 1,053 acute care emergency surgery, 1,964 general surgery, 1,491 transplant surgery, 995 facial surgery/otolaryngology, and 595 neurosurgery. Acute care emergency surgery patients had statistically significantly longer ICU lengths of stay than other groups: acute care emergency surgery (13.5 ± 17.4 d) versus general surgery (8.7 ± 12.9), transplant (7.8 ± 11.6), oral-maxillofacial surgery (5.5 ± 4.2), and neurosurgery (4.47 ± 9.8) (all p< 0.01). Ventilator usage, defined by percentage of total ICU days patients required mechanical ventilation, was significantly higher for acute care emergency surgery patients: acute care emergency surgery 73.4% versus general surgery 64.9%, transplant 63.3%, oral-maxillofacial surgery 58.4%, and neurosurgery 53.1% (all p < 0.01). Continuous renal replacement therapy usage, defined as percent of patients requiring this service, was significantly higher in acute care emergency surgery patients: acute care emergency surgery 10.8% versus general surgery 4.3%, transplant 6.6%, oral-maxillofacial surgery 0%, and neurosurgery 0.5% (all p < 0.01). Acute care emergency surgery patients were more likely interhospital transfers for tertiary care services than general surgery or transplant (24.5% vs 15.5% and 8.3% respectively, p < 0.001 for each) and more likely required emergent surgery (13.7% vs 6.7% and 3.5%, all p < 0.001). Chronic comorbidities were similar between acute care emergency surgery and general surgery, whereas transplant had fewer. CONCLUSIONS: Emergency general surgery patients have increased ICU needs in terms of length of stay, ventilator usage, and continuous renal replacement therapy usage compared with other services, perhaps due to the higher percentage of transfers and emergent surgery required. These patients represent a distinct population. Understanding their resource needs will allow for better deployment of hospital resources.

Surgical intensive care unit admission variables predict subsequent readmission.

Intensive care unit (ICU) readmissions are associated with increased resource use. Defining predictors may improve resource use. Surgical ICU patients requiring readmission will have different characteristics than those who do not. We conducted a retrospective cohort study of a prospectively maintained database. The Acute Physiology and Chronic Health Evaluation (APACHE) IV quality database identified patients admitted January 1 through December 31, 2011. Patients were divided into groups: NREA = patients admitted to the ICU, discharged, and not readmitted versus REA = patients admitted to the ICU, discharged, and readmitted. Comparisons were made at index admission, not readmission. Categorical variables were compared by Fisher's exact testing and continuous variables by t test. Multivariate logistic regression identified independent predictors of readmission. There were 765 admissions. Seventy-seven patients required readmission 94 times (12.8% rate). Sixty-two patients died on initial ICU admission. Admission severity of illness was significantly higher (APACHE III score: 69.54 ± 21.11 vs 54.88 ± 23.48) in the REA group. Discharge acute physiology scores were equal between groups (47.0 ± 39.2 vs 44.2 ± 34.0, P = nonsignificant). In multivariate analysis, REA patients were more likely admitted to emergency surgery (odds ratio, 1.9; 95% confidence interval, 1.01 ± 3.5) more likely to have a history of immunosuppression (2.7, 1.4 ± 5.3) or higher Acute Physiology Score (1.02; 1.0 ± 1.03) than NREA. Patients who require ICU readmission have a different admission profile than those who do not "bounce back." Understanding these differences may allow for quality improvement projects such as instituting different discharge criteria for different patient populations.

Laparoscopically assisted components separation technique for ventral incisional hernia repair.

Reconstruction of the abdominal wall to repair ventral hernias continues to pose a challenge to surgeons due to relatively high rates of recurrence and morbidity. In 1990, Ramirez pioneered a technique of components separation of the abdominal wall for ventral hernia repair. Although an effective hernia repair, the mobilization of skin and subcutaneous tissue endangers the blood supply and predisposes midline skin to necrosis. The goal of this study is to determine whether releasing incisions in the transversus abdominis fascia and posterior rectus sheath provide adequate mobilization of the abdominal wall necessary for ventral hernia repair, thus paving the way for a laparoscopic component separation technique. Ten fresh cadavers were used and one side of the abdomen underwent the conventional Ramirez components separation: midline incision, dissection of skin and subcutaneous tissue off the anterior abdominal wall, and incisions in the external oblique aponeurosis and posterior rectus sheath, while the other side received incisions in the transversus abdominis fascia and the posterior rectus sheath with no undermining of the skin. The amount of fascial translation was measured after each incision. Incising only the external oblique aponeurosis produced greater mobilization of the abdominal wall at the level of the umbilicus (P = 0.02) and anterior superior iliac spine (ASIS, P = 0.029) than releasing only transversus abdominis fascia. More importantly, there was no statistically significant difference in the amount of release produced by the complete internal-release components separation versus the conventional technique. In order to test the feasibility of performing the procedure laparoscopically, one additional cadaver underwent a laparoscopic transversus abdominis fascia release. The procedure was successful and resulted in comparable amounts of fascial release as the other 10 cadavers. From this study, it appears technically feasible to perform a laparoscopic components separation to repair a ventral hernia and the procedure produces the same amount of release as the conventional open component separation technique.

Elevated remnant-like particle cholesterol and triglyceride levels in diabetic men and women in the Framingham Offspring Study.

OBJECTIVE: Remnants of triglyceride-rich lipoproteins are thought to be atherogenic. A new antibody-based assay allows for the isolation of remnant-like particles (RLPs) from plasma or serum, and the subsequent measurement of RLP cholesterol (RLPC) and triglycerides (RLPTGs). We hypothesized that diabetic patients would have higher remnant levels than nondiabetic patients. DESIGN AND METHODS: We compared RLPC and RLPTG levels of diabetic subjects (68 women, 121 men) participating in the Framingham Heart Study with those of nondiabetic subjects (1,499 women, 1,357 men). RESULTS: Mean RLPC values for diabetic women were 106% higher than those for nondiabetic women (0.367 +/- 0.546 mmol/l [14.2 +/- 21.1 mg/dl] vs. 0.179 +/- 0.109 mmol/l [6.9 +/- 4.2 mg/dl]; P < 0.0001), and RLPTG values for diabetic women were 385% higher than those for nondiabetic women (1.089 +/- 2.775 mmol/l [93.1 +/- 245.6 mg/dl] vs. 0.217 +/- 0.235 mmol/l [19.2 +/- 20.8 mg/dl]; P < 0.0001). Similar but less striking differences were observed in diabetic men, who had mean RLPC values 28% higher than those seen in nondiabetic men (0.285 +/- 0.261 mmol/l [11.0 +/- 10.1 mg/dl] vs. 0.223 +/- 0.163 mmol/l [8.6 +/- 6.3 mg/dl]; P < 0.001) and mean RLPTG values 70% higher than those seen in nondiabetic men (0.606 +/- 1.019 mmol/l [53.6 +/- 90.2 mg/dl] vs. 0.357 +/- 0.546 mmol/l [31.6 +/- 48.3 mg/dl]; P < 0.001). Moreover, diabetic men and women had significantly higher total triglycerides and lower HDL cholesterol levels than nondiabetic subjects. CONCLUSIONS: The data indicate that RLP particles are elevated in diabetic subjects. To achieve optimal reduction of risk for cardiovascular disease, treatment of elevated RLP values, along with the control of LDL cholesterol levels, should be considered.