Infectious aortitis and managing it at a community military hospital.

Infectious aortitis is a rare disease process which can be of fungal, viral or bacterial aetiology. This disease process is often incidentally found during concomitant infectious processes, likely due to haematogenous spread. Common sources are from cardiac, genitourinary and gastroenterologic sources. CT imaging of the aorta is essential in identifying physiological changes-wall thickness changes, ectasia and stenosis. We present a case of a female in her early 60s with a medical history of cardiomyopathy with heart failure and reduced ejection fraction, who was initially admitted for acute cholecystitis complicated by the development of gallstone pancreatitis. Imaging evaluation incidentally noted findings consistent with aortitis with a penetrating ulcer, and blood cultures were positive for Staphylococcus aureus bacteraemia, confirming her diagnosis of infectious aortitis. She was started on intravenous antibiotics, required preoperative nutritional optimisation, and subsequently underwent an open aortic resection and aortoiliac reconstruction with rifampin-soaked Dacron graft.

Clinical Image: Visual Estimation of Blood Loss.

Military prehospital providers frequently have to make important clinical decisions with only limited objective information and vital signs. Because of this, accurate estimation of blood loss, at the point of injury, can augment any available objective information. Prior studies have shown that individuals significantly overestimate the amount of blood loss when the amount of hemorrhage is small, and they tend to underestimate the amount of blood loss with larger amounts of hemorrhage. Furthermore, the type of surface on which the blood is deposited can impact the visual estimation of the amount of hemorrhage. To aid providers with the ability to accurately estimate blood loss, we took several units of expired packed red blood cells and deposited them in different ways on varying surfaces to mimic the visual impression of combat casualties.

Cellular changes of the colon after mechanical bowel preparation.

BACKGROUND: The purpose of this study was to evaluate the effect of mechanical bowel preparation (MBP) on the intracellular environment, specifically evaluating butyrate transport, within the colon of the Sprague-Dawley rat. METHODS: Sixty-eight Sprague-Dawley rats were randomized to either an MBP group (n = 34) or a control group (n = 34). Twenty-four hours after the completion of the MBP, both groups were euthanized, and the colons were harvested. The level of cellular apoptosis was investigated after DNA fragmentation, poly(ADP-ribose) polymerase cleavage, and caspase assays. Western blot analysis was performed to measure the expression of the butyrate transporter protein, monocarboxylate transporters 1, and proliferating cell nuclear antigen (a marker for tissue proliferation). Immunohistochemical staining was performed to further investigate cellular proliferation. Statistical significance (P < 0.05) was determined using two-tailed t-test. RESULTS: Apoptosis was detected without significant differences in both groups. Western Blot analysis demonstrated that the expression of the monocarboxylate transporters 1 protein is downregulated in the MBP group (10.18 ± 3.09) compared with the control group (16.73 ± 7.39, P = 0.001), and proliferating cell nuclear antigen levels showed a decrease in cellular proliferation in the MBP group (13.35 ± 5.88) compared with the control (20.07 ± 7.55, P = 0.018). Immunohistochemistry confirmed a decrease in cellular proliferation after MBP with 23.4 ± 7.8% of the cells staining positive for Ki-67 in the MBP group versus 28.6 ± 7.9% in the control group (P = 0.006). CONCLUSIONS: MBP has a negative impact on cellular proliferation and intracellular transport of butyrate within the rat colon, not related to apoptosis. This is the first study to demonstrate the intracellular effects that MBP has on the rat colon.

Postoperative pneumoperitoneum on computed tomography: is the operation to blame?

BACKGROUND: Postoperative radiographs demonstrating pneumoperitoneum are a vexing problem for surgeons. This dilemma stems from uncertainty regarding the length of time for resolution of gas introduced operatively via either an open or a laparoscopic approach. We attempted to quantify the duration of pneumoperitoneum after both laparoscopic and open surgery in an animal model. METHODS: A prospective study using 2 groups of 10 pigs (Sus scrofa) was performed. The animals were assigned to undergo either an exploratory laparoscopy or an open abdominal exploration. Postoperatively, sequential computed tomography (CT) scans were performed to assess for the presence of pneumoperitoneum. RESULTS: Pneumoperitoneum resolution occurred sooner than average on CT scan in the laparoscopic group when compared to open group (1.79 days vs 4.73 days respectively; P value of .02). CONCLUSIONS: Postoperative pneumoperitoneum resolves more quickly after laparoscopy when compared to open surgery in the porcine model. This information may aid in evaluating postoperative CT scans demonstrating pneumoperitoneum.

Surgical management and associated complications of penetrating rectal injuries sustained in Iraq and Afghanistan.

PURPOSE: The aim of this study was to analyze the surgical management and associated complications of penetrating rectal injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom. METHODS: A retrospective review was performed using the Joint Theater Trauma Registry. U.S. military personnel injured in Iraq and Afghanistan from October 2003 to November 2008 were included. The surgical management of rectal injuries was evaluated, specifically looking at the utilization of diversion with ostomy, distal washout, and presacral drainage. Complications were compared between the treatment groups. RESULTS: 57 patients who sustained a penetrating rectal injury were included in this study. Surgical management included diversion and ostomy alone in 34 patients (60%), diversion and distal washout in 11 patients (19%), diversion and drainage in 8 patients (14%), and diversion, distal washout, and drainage in 4 patients (7%). Complications were identified in 21% of patients. There were no deaths in the study group. Logistical regression failed to show a correlation between postoperative complications with either distal washout (p = 0.33) or presacral drainage (p = 0.9). CONCLUSIONS: The majority of patients were successfully managed with fecal diversion alone, suggesting that drainage and distal washout may be unnecessary steps in the management of high-velocity, penetrating rectal injuries.