Could blunt trauma lead to a double lumen esophagus?

INTRODUCTION AND IMPORTANCE

Esophageal rupture and perforation are serious complications of blunt abdominal trauma. Early diagnosis and intervention is key for patient survival. Studies have reported that mortality of patients with esophageal perforation can be as high as 20-40 % (Schweigert et al., 2016; Deng et al., 2021 [1, 2]). We present a patient with suspected esophageal perforation after a blunt trauma identified by esophagogastroduodenoscopy (EGD) as the presence of a second gastroesophageal lumen concerning for esophagogastric fistula.

CASE PRESENTATION

Our patient is a 17-year-old male with no past medical history who was brought in from an outside facility status post electric bike accident. CT imaging from an outside hospital showed concern for possible esophageal rupture. On arrival, he was in no acute distress. Patient underwent a fluoroscopy upper GI series which showed extravasation of fluid outside the lumen, indicating an esophageal injury. Patient was evaluated by Gastroenterology and Cardiothoracic surgery, who agreed on an empiric course of piperacillin/tazobactam and fluconazole for prophylaxis in the setting of suspected esophageal rupture. Patient underwent an esophagram with EGD which demonstrated a 2nd false lumen from 40 to 45 cm. This appeared to be from incomplete avulsion of the submucosal space. No contrast extravasation was seen with the esophagram.

CLINICAL DISCUSSION

To date, there has been no published case of trauma induced formation of a double lumen esophagus. Our patient presented with no previous history to suggest chronic or congenital double lumen of the esophagus.

CONCLUSION

When considering esophageal rupture, the possibility of the formation of an esophago-gastric fistula should be considered via external traumatic insult.

Compliance With Surgical Oncology Specialty Care at a Safety Net Facility

BACKGROUND

Social determinants of health challenge in at-risk patients seen in safety net facilities.

STUDY DESIGN

We performed a retrospective review of surgical oncology specialty clinic referrals at a safety net institution evaluating referral compliance and times to first appointment and initiation of definitive treatment. Main outcomes measured included completion of initial visit, initiation of definitive treatment, time from referral to first appointment, and time from first appointment to initiation of definitive treatment.

RESULTS

Of 189 new referrals, English was not spoken by 52.4% and 69.4% were Hispanic. Patients presented without insurance in 39.2% of cases. Electronic patient portal was accessed by 31.6% of patients. Of all new referrals, 55.0% arrived for initial consultation and 53.4% initiated definitive treatment. Malignant diagnosis (P < .0001) and lack of insurance (P = .01) were associated with completing initial consultation. Initiation of definitive treatment was associated with not speaking English (P = .03), malignant diagnosis (P < .0001), and lack of insurance (P = .03). Times to first appointment and initiation of definitive treatment were not significantly affected by race/ethnicity, language, insurance, treatment recommended, or electronic patient portal access.

CONCLUSION

Access to surgical oncology care for at-risk patients at a safety net facility is not adversely affected by lack of insurance, primary spoken language, or race/ethnicity. However, a significant proportion of all patients fail to complete the initial consultation and definitive treatment. Lessons learned from safety net facilities may help to inform disparities in health care found elsewhere.

Associate Program Directors in Surgery: A Select Group of Surgical Educators

OBJECTIVE

The role of the Associate Program Director (APD) within surgical education is not clearly defined or regulated by the Accreditation Council for Graduate Medical Education, often leading to variations in the responsibilities among institutions. Required credentials are not specified and compensation and protected time are not regulated resulting in large discrepancies among institutions. APDs are brought into the fold of surgical education to parcel out the escalating responsibilities of program director (PD). The Association of Program Directors in Surgery, Associate Program Directors Committee sent a survey to all APDs to better understand the role of the APDs within the hierarchy of surgical education.

DESIGN

A survey was sent to all 235 general surgery residency programs through the Association of Program Directors in Surgery list serve. The survey collected information on APD demographics, characteristics, and program information, qualifications of the APD, time commitment and compensation, administrative duties, and projected career track.

SETTING

General surgery residency programs within the United States.

PARTICIPANTS

108 Associate Program Directors in general surgery RESULTS: A total of 108 (46%) APDs responded to the survey. Seventy-three (70.2%) of the APD's were males. Most (77.8%) were in practice for more than 5 years, and 69% were at a university-based program. Most of the respondents felt that the administrative and curricular tasks were appropriately distributed between the APD and PD and many shared tasks with the PD. A total of 44.6% were on the path to become a future PD at their institution. An equal number of APDs (42.6%) were compensated above their base salary for being an APD vs no compensation at all; however, 16 (14.8%) had a reduced clinical load as part of their compensation for being an APD.

CONCLUSION

This is the first study to describe the characteristics of APDs within the hierarchy of surgical education. Our data demonstrate that APDs have a substantial role in the function of a residency program and they need to be developed to better define their position in the program leadership.

A prospective analysis of critical limb ischemia: factors leading to major primary amputation versus revascularization

In our aging population, primary major amputations (AMP, below-knee or above-knee) continue to be performed despite advances in revascularization. We hypothesized that not only patient comorbidities but also the system of health-care delivery affected the treatment of patients with critical limb ischemia (CLI). A prospective analysis of patients presenting with CLI was undertaken to determine whether patient-specific factors or healthcare delivery factors (system-related) influenced treatment with primary AMP versus lower extremity revascularization (LER). The patient-specific factors age, gender, race/ethnicity, presence of coronary artery disease, cerebrovascular disease, tobacco use, diabetes mellitus (DM), dialysis dependence (end-stage renal disease, ESRD), hypertension, hyperlipidemia, stage of CLI (rest pain, minor or major tissue loss), history of revascularization, and functional status (living situation and ambulatory status) were recorded. The system-related factors time from onset of CLI to vascular surgery evaluation and type of insurance (managed care/other insurance) were also noted. The influence of patient-specific and system-related factors on the primary treatment modality (AMP versus LER) was determined with univariate and multivariate analyses. A total of 224 patients presented with CLI between March 1, 2001, and March 1, 2005. Patients were treated with primary major AMP in 97 cases (43%) and revascularization in 127 cases (57%). On univariate analysis, nonwhite race/ethnicity, DM, ESRD, major tissue loss, dependent living situation, and nonambulatory status were all significant predictors of AMP versus LER (all P < 0.01). On multivariate analysis, major tissue loss, ESRD, DM, and nonambulatory status remained independent predictors of AMP versus LER (all P < 0.05). The system-related factors of time to vascular surgery evaluation (mean 8.6 weeks, 7.1 vs. 9.3 weeks AMP versus LER, P = 0.60) and type of insurance (managed care, 17% vs. 24% AMP vs. LER, P = 0.15) had no influence on treatment. Fifty-four percent of all primary major AMPs were performed due to extensive gangrene or infection present at initial vascular evaluation which precluded limb salvage. Major tissue loss, ESRD, DM, and nonambulatory status are all independent predictors of treatment with primary AMP as opposed to revascularization. Treatment of CLI is determined by patient-specific factors and does not appear to be adversely influenced by system-related factors. Efforts toward improving limb salvage may be best directed at aggressive treatment of medical comorbidities to prevent the late complications of CLI. Earlier recognition of tissue loss and referral to the vascular specialist may lead to improved limb salvage.