A simple risk score for predicting surgical site infections in inflammatory bowel disease.

PURPOSE: Patients with inflammatory bowel disease are often at highest risk for surgical site infections. We sought to define the predictors of surgical site infections and to develop a risk score for predicting those at highest risk. METHODS: Patients undergoing a bowel resection for Crohn's disease or ulcerative colitis were identified from National Surgical Quality Improvement Program 2008. Univariate and multivariate analyses were conducted to identify predictors of surgical site infections. Clinically relevant prediction categories were developed and the predictive behavior of the model was validated by use of National Surgical Quality Improvement Program 2007. An integer-based scoring system risk score was created proportional to the logistic regression coefficients, grouping patients into categories of similar risk. RESULTS: We identified 271,368 patients; 3981 of these patients underwent an operation for Crohn's disease (n = 2895) or ulcerative colitis (n = 1086). Nine hundred (22.6%) patients developed surgical site infections. Predictors included weight loss, smoking, emergent surgery, wound class, operative time (minutes), and an ASA score >2. A risk score was developed by stratifying patients into low (0-5), 15.6%; medium (6-8), 25.2%; and high (>8), 36.1% risk. CONCLUSIONS: Patients with inflammatory bowel disease are at high risk for surgical site infections. Preoperative factors including weight loss, smoking, emergent surgery and an ASA score >2 are strong predictors of surgical site infections. Operative time and wound class are important intraoperative predictors. A risk score, based on pre- and intraoperative variables, can be used to identify patients at highest risk of developing surgical site infections. This may allow for appropriate process measures to be implemented to prevent and lessen the impact of surgical site infections in this high-risk population.

Experience with endoluminal colonic wall stents for the management of large bowel obstruction for benign and malignant disease.

HYPOTHESIS: To assess the applicability and efficacy of endoluminal colonic wall stents (ECWSs) in the management of large bowel obstruction (LBO). DESIGN: Inception cohort study. SETTING: University-based tertiary medical center. PATIENTS: Eleven consecutive patients with LBO in the absence of peritonitis. INTERVENTION: Placement of ECWS under endoscopic and fluoroscopic guidance. MAIN OUTCOME MEASURES: The success rate in ECWS placement, the efficacy in decompressing the obstruction, and the patency rate of the ECWS. RESULTS: Successful placement of ECWSs was obtainable in 10 of 11 patients. Once placed, all 10 patients achieved immediate decompression of their LBO. Eight patients had malignant obstructions associated with distant spread of disease; 3 patients had diverticular disease. Among those with malignant obstruction, 6 patients had successful and lasting palliation without colostomy, 1 patient underwent 1-stage resection 1 month later with no evidence of obstruction, and 1 patient could not be stented so diversion was done. None of the patients with diverticular disease required diversion: 2 had complete bowel preparation followed by resection with primary anastomosis, whereas the third declined surgery. Four of the 10 patients required overlapping ECWSs to bridge the stricture. One patient required a second ECWS secondary to recurrence of obstruction after stent migration and has continued palliation of his stage 4 rectal cancer for the last 11 months. No other complications were encountered. CONCLUSIONS: Urgent surgery with colostomy for LBO was avoided in 10 of 11 patients because of successful placement of ECWSs. We believe that endoscopic colonic stenting is safe, effective, and lasting, and should be considered as initial nonoperative management in all patients seen with LBO in the absence of peritonitis.

Intravascular bronchioloalveolar tumor: a distinctive surgical and pathological entity.

A patient with intravascular bronchioloalveolar tumor is described, and the clinical and pathological characteristics of the tumor are discussed. So-called intravascular bronchioloalveolar tumor (IVBAT) is a relatively new, but well-recognized lung neoplasm. This tumor is a lung neoplasm of distinctive histogenesis newly incorporated into the World Health Organization histologic typing of lung tumors under the category "miscellaneous tumors, malignant." The importance of the neoplasm is that it is rarely recognized clinically and frequently misdiagnosed. Awareness of this lesion can be enhanced by recognizing its particular clinical presentation, surgical appearance, and unique histopathologic factors.

Results of 1,000 single-layer continuous polypropylene intestinal anastomoses.

Between 1979 and 1988, we created intestinal anastomoses in 1,000 patients using a single-layer, continuous suturing technique and a polypropylene suture. The technique is easily learned, flexible in its application, and incurs less cost than most other techniques. The anastomoses involved all levels of the colon and the upper (intraperitoneal and extraperitoneal) rectum. All patients were followed for a minimum of 1 year. The clinically suspected anastomotic leak rate was 1%. Other morbidity included would complications (2%), obstruction of the small intestine (2%), anastomotic stricture (1%), and death (1%). No death was due to anastomotic complications. These rates of complications are comparable with, and in many instances lower than, those reported with other techniques of intestinal anastomosis.

A modified method of vascular access system implantation using the subclavian vein.

A new method of implanting vascular access systems using the Arrow Percutaneous Sheath Introducer Kit is described. The surgeon who frequently inserts these systems may find this technique to be a useful alternative in those patients in whom cutdowns were unsuccessful or in whom the percutaneous technique with a peel-away sheath is found to be difficult.

All-terrain vehicle injuries. A review at a rural level II trauma center.

All-terrain vehicles (ATVs) have become a major source of morbidity and mortality with more than 600 deaths nationwide. Nearly half of those injured are children under 16 years. Twenty three ATV accidents were seen at the Guthrie Medical Center over a 30 month period ending in August 1986. Ten patients (43.5%) were under 16 years old. Of those injured who were older, alcohol was involved in 70 per cent of the accidents. Five accidents occurred on highways (21.7%), in spite of laws banning their use on public roads. Rollover type accidents and collisions were the most frequent mechanisms of injury (39% and 35%). Of 18 patients known not to have worn a helmet, 61 per cent sustained a closed head injury. In all, there were 88 injuries in 23 patients. Common injuries included lacerations (13), long bone fractures (13), renal contusions (11) and head injury (11). There were two deaths (8.7%), two cord transections with permanent disability, and a below-knee amputation. ATVs present a serious hazard to adult and children riders alike. Age limits, state licensing, safety programs, and protective equipment are all recommended as a means to reduce injury and death from recreational riding.

Independent predictors of morbidity and mortality in blunt colon trauma.

We sought to determine the impact of (1) grade of the colon injury, (2) the formation of an ostomy, and (3) associated injuries on outcomes such as morbidity and mortality after blunt colon injuries. We retrospectively reviewed 16,814 cases of blunt abdominal trauma. Patients with colonic injuries were selected and charts reviewed for demographic, clinical, and outcomes data. Injuries were grouped by the Colon Injury Scale (grades I-V). Independent risk factors of morbidity included spine and lung injuries, as well as increased age. A higher grade of colon injury trended toward a significant association with intra-abdominal complications. Independent risk factors of mortality included liver, heart, and lung injuries, as well as intracerebral blood and female gender. The grade of colon injury, the formation of an ostomy, and management of the colon trauma did not independently predict increased intra-abdominal complications, morbidity, or mortality. These results indicate that patients afflicted with blunt colon trauma experience a high rate of morbidity and mortality from associated injuries and or increased age. Treatment regimens directed at these factors will be most helpful in reducing the high morbidity and mortality after blunt colon trauma. Factors such as ostomy formation and management strategy are not associated with increased morbidity or mortality after blunt colon trauma.

A method for shipboard treatment of multiple heat casualties.

A method is presented for the treatment aboard ship of multiple patients afflicted with life-threatening heat illness, using an inflatable life raft cooling system. The potential benefits of this method include: (1) the utilization of readily available materials aboard U.S. Naval vessels; (2) the provision for rapid patient cooling by evaporation while maintaining patient safety and comfort; (3) the ability to treat many patients simultaneously with minimal attendant personnel; and (4) the maintenance of patient access allowing for monitoring and the administration of additional supportive measures.

The constipated serviceman: prevalence among deployed U.S. troops.

The prevalence of constipation in deployed servicemen was determined in a sample of military personnel aboard the USS Iwo Jima LPH 2 during Operation Desert Shield. Results were obtained from a bowel function questionnaire issued to 500 deployed marines and sailors. When constipation is defined as no bowel movement for greater than 3 days, 3.9% of the Marine/sailor personnel are constipated when in their home environment as compared to 6.0% when they are aboard ship and 30.2% while in the field. Alternatively, when constipation is defined as the presence of certain anorectal complaints (hard stools, straining, painful defecation, and bleeding with defecation), the incidence is 7.2% when at home as compared to 10.4% aboard ship and 34.1% in the field. These results confirm that whether constipation is defined as infrequent bowel movements or presence of symptoms of constipation, significantly more servicemen will be constipated when in the field as compared to their home environment. Since approximately one-third of Navy/Marine Corps personnel deployed in a field environment will be constipated, preventive measures ought to be evaluated.

Racial differences in short-term surgical outcomes following surgery for diverticulitis.

BACKGROUND: Diverticular disease ranks as one of the more common gastrointestinal disorders among westernized nations. Few studies have examined racial differences in the care and surgical outcomes of diverticulitis. The aim of this study was to determine if race is a predictor of peri-operative morbidity and mortality following surgery for diverticulitis. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (2005-2008) was queried with the primary dependent variables being 30-day morbidity and mortality. Differences in morbidity and mortality between races were compared using χ (2) and Student t tests. Logistic regression was used to calculate odds ratios for morbidity and mortality. To determine if the effect of race is modified by insurance status and case complexity, additional models were developed across age subgroups (<65 vs ≥ 65) and levels of case complexity. RESULTS: We identified 4,709 white and 360 African American patients. Despite being younger (57.6 ± 0.74 vs 59 ± 0.2, p < 0.05), African Americans were more likely to present with hypertension, diabetes, renal failure, dependent functional status, American Society of Anesthesiology class ≥ 3 (all p < 0.0001) and were more likely to require urgent surgery (p < 0.05), intra-operative blood transfusions(p < 0.0001), and undergo open colectomy (p < 0.0001). On adjusted analysis, African American race emerged as an independent predictor of morbidity (p < 0.05) and mortality (p < 0.05), without differences across insurance categories and less complex procedures. African American race remained a strong predictor of morbidity in more complex procedures (p < 0.05). CONCLUSION: African Americans undergoing surgery for diverticulitis are more likely to have associated co-morbidities, require urgent surgery, undergo open surgery, and are at increased risk of morbidity and mortality. These findings highlight a need to address the root cause for disparities in care and outcomes after surgery.

Local excision of rectal tumors: specimen orientation.

Transanal local excision is a management option for patients with rectal tumors. An important final step in this operation is specimen orientation. A simple technique is described for specimen preparation, ideally performed by the surgeon in the operating room. This technique is recommended as the concluding step, for it can be as important as the local excision itself in regard to the determination of adequacy of resection and the need for additional treatment.

Modified Kraske approach for disease of the mid-rectum.

A modification of Dr. Paul Kraske's approach for removal of mid-rectal lesions has been used in 11 patients from 1977 to 1988 by the senior authors. Patients ranged in age from 56 to 89 yr, with an average of 67 yr. There were seven male and four female patients. Indications for surgery were as follows: villous adenoma (seven), carcinoid (one), recurrent dysplasia in a previous endoscopic polypectomy site (one), positive distal margin for neoplasm following low anterior sigmoid resection (one), and adenocarcinoma in one elderly poor-risk patient. All lesions were in the middle rectum (7-11 cm from the anal verge, average 9 cm). The postoperative stay ranged from 6 to 12 days with a mean of 8 days. The average follow-up for the 11 patients is 3 1/2 yr (1 month to 7 yr), with only one patient having a local recurrent lesion. There was no morbidity or mortality. We conclude that this modification of the Kraske approach offers a good alternative for excision of mid-rectal lesions in terms of technical ease, efficacy, safety, and patient tolerance. The modified Kraske approach is indicated in certain situations and should be a part of the surgeon's armamentarium.

Endoluminal stenting for benign colonic obstruction.

We report a case of complete descending colon obstruction due to diverticular disease that was initially managed by endoscopic stent placement followed by single-stage left colectomy with primary anastomosis. Traditional management of complete large bowel obstruction, whether due to benign or malignant disease, most often requires a temporary colostomy because of unprepared colon. In this case, preparation of the colon was accomplished by successful stenting of the benign colonic obstruction. We believe that endoscopic colonic stenting is an effective way of avoiding a temporary colostomy in patients with complete large bowel obstruction.

Rectal prolapse associated with bulimia nervosa: report of seven cases.

PURPOSE: Rectal prolapse is a condition in which, when complete, the full thickness of the rectal wall protrudes through the anus. Bulimia nervosa is an eating disorder characterized by periodic food binges, which are followed by purging. Purging usually takes the form of self-induced vomiting, laxative abuse, and/or diuretic abuse. We report seven cases of rectal prolapse associated with bulimia nervosa. METHODS: The case histories of seven women with rectal prolapse and bulimia nervosa, average age 29 (range 21-42) years, seen over a period of 11 years (1987-1997) were reviewed. An analysis of the clinical data, including history, presenting physical examination, surgical treatment, and outcome was performed. RESULTS: All seven patients had a diagnosis of bulimia nervosa, made either before or with a diagnosis of rectal prolapse. Rectal prolapse was confirmed in each patient at anorectal examination. Five patients underwent sigmoid resection with proctopexy, one died before operative therapy, and one awaits further treatment. One of the five surgical patients had a recurrence that was managed by a perineal rectosigmoidectomy. CONCLUSION: To our knowledge, despite extensive review of both bulimia nervosa and rectal prolapse as seen in the medical literature, an association between the two has not been described previously. Several aspects of bulimia nervosa, including constipation, laxative use, overzealous exercise, and increased intra-abdominal pressure from forced vomiting are likely causes for the probable relationship with rectal prolapse. The possibility that an atypically young female presenting with rectal prolapse may also have bulimia nervosa should be taken into account by clinicians. This may assist the diagnosis of bulimia nervosa, a disease with multiple morbidities. Conversely, a patient being treated for bulimia nervosa who develops anorectal symptoms may come to earlier diagnosis and treatment for rectal prolapse.

Late recurrence of malignant melanoma.

A patient presented with metastatic disease nearly 12 years after initial excision of a "benign" nevus. Review of the original slides confirmed malignant melanoma. Another patient was found to have a metastatic deposit of melanoma in the breast 23 years after an apparently adequate excision of a melanoma on the back. The natural history of this tumor shows its unpredictable nature. A thorough history and lifelong follow-up are essential in patients with malignant melanoma.

Antibiotic-associated fulminant pseudomembranous colitis without toxic megacolon.

Presented is a middle-aged male who developed a fulminant case of antibiotic-associated pseudomembranous colitis characterized by leukocytosis, hypoalbuminemia, ascites, and anasarca without toxic megacolon. The patient responded slowly to medical therapy consisting of intravenous metronidazole, oral vancomycin, and parenteral nutrition. Subsequently, cholestyramine was administered. A review of the literature concerning similar cases of fulminant pseudomembranous colitis is presented.

Effect of music therapy on state anxiety in patients undergoing flexible sigmoidoscopy.

PURPOSE: Patient anxiety related to flexible sigmoidoscopy can negatively affect acceptability and compliance with screening protocol, complicate and prolong procedure time, and potentially result in prematurely aborted procedures. Music has been recognized through research as a safe, inexpensive, and effective nonpharmaceutical anxiolitic agent. METHODS: An experimental study was performed on 50 adults scheduled for outpatient sigmoidoscopy. The control group received standard sigmoidoscopy protocol. Subjects in the experimental group received the standard protocol with the addition of listening to music throughout the procedure. State-Trait Anxiety Inventory (STAI) measurements were performed on all subjects before and postsigmoidoscopy. Physiologic recordings of heart rate and mean arterial pressure were recorded before and during the procedure. RESULTS: Patients who listened to self-selected music tapes during the procedure had significantly decreased STAI scores (P < 0.002), heart rates (P < 0.03), and mean arterial pressures (P < 0.001) in comparison to the control subjects. CONCLUSION: The results of the study indicate that music is an effective anxiolitic adjunct to flexible sigmoidoscopy.

Kock pouch dysfunction during pregnancy. Management of a case.

The Kock continent ileostomy is a surgical alternative to a Brooke ileostomy after total proctocolectomy. Complications resulting from an improperly functioning nipple valve are not infrequent and when they occur most often require surgical revision. A 19-year-old female with a functioning Kock pouch of 4 years presented at 6 months of pregnancy with complete bowel obstruction due to nipple valve dysfunction. Operative management was avoided and her bowel obstruction was relieved by endoscopic placement of a stent through the nipple valve and into the abdominal reservoir. The stent was removed at 1 week postpartum with immediate return to normal function of her Kock pouch nipple valve. Temporary malfunction of the Kock pouch nipple valve can occur during pregnancy, probably due to distortion of the valve mechanism by the enlarging uterus. The endoscopic placement of a stent can maintain proper bowel evacuation until delivery and normal Kock pouch function can be expected after stent removal.

What is the normal aganglionic segment of anorectum in adults?

INTRODUCTION: Ultrashort-segment Hirschsprung's disease as a cause of obstructed defecation is controversial because of a lack of knowledge regarding the normal aganglionic zone of the distal rectum. The intent of this study was to define the normal aganglionic zone of the distal rectum through histologic review of cadaveric dissections. METHODS: Cadavers were obtained from the anatomic pathology laboratory at the University of Massachusetts Medical School. Strip myectomy with overlying mucosa was performed from distal to the dentate line to at least 3 cm into the anal canal and rectum after the pelvis was hemisected. Specimens were fixed in 10 percent buffered formalin. Specimens were sectioned serially every 3 mm and embedded in paraffin. Four-micron slices were then stained with hematoxylin and eosin. Each section was examined by a gastrointestinal pathologist. The presence or absence of nerves and ganglion cells was recorded. RESULTS: Thiry cadavers were obtained for analysis. Mean age at time of death was 79 (range, 65-97) years. There were 13 men. The mean distance of aganglionic bowel from the dentate line was 6.6 (range, 0-21) mm in Meissner's plexus and 5.1 (range, 0-15) mm in Auerbach's plexus. CONCLUSION: The normal distance of aganglionic bowel wall is 2 cm or less from the dentate line. The absence of ganglion cells proximal to this normal aganglionic zone in the patient with clinical findings of lifelong obstructed defecation defines ultrashort-segment Hirschsprung's disease.