A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis

BACKGROUND/PURPOSE

This study examines the safety and patient satisfaction in discharging children undergoing laparoscopic appendectomy (LapAppy) for acute appendicitis on the day of surgery.

METHODS

After institutional review board approval, data were collected prospectively for 158 consecutive patients undergoing LapAppy for simple appendicitis. Time from operation to discharge and complications were analyzed. At follow-up, parents completed a satisfaction survey. The Student t test was used for statistical analysis.

RESULTS

Laparoscopic appendectomy was performed in 158 children ranging from age 2 to 19 years (mean, 12 years) over a 6-month period. Single-port, single-instrument LapAppy was possible in 152 patients (96%). Eighty percent of patients (n = 126) were discharged on the day of surgery, a mean of 4.8 hours postoperatively (range, 1-12 hours). Of the remaining 32, 24 (75%) were admitted because the operation ended too late for postoperative discharge; 3 (9%), for medical reasons; and 5 (16%), when the families declined to leave. One hundred nine parents (87%) whose children went home postoperatively stated that they were happy with the expeditious discharge, whereas 17 (13%) felt nervous. In addition, 116 parents (92%) stated that, in retrospect, same-day discharge was preferable, whereas 10 parents (8%) were not sure that it was the best decision. None, however, would insist on admission if faced with the situation again. There were no major complications and no significant difference in the rate of umbilical wound infections for same-day discharge patients (2%) and admitted patients (3%).

CONCLUSION

Routine same-day discharge after pediatric LapAppy for acute appendicitis is safe, with good parent satisfaction.

Intracranial Pressure Monitoring in Children With Severe Traumatic Brain Injury: National Trauma Data Bank-Based Review of Outcomes

IMPORTANCE

The present study is the largest on the use and effect of intracranial pressure (ICP) monitoring in pediatric trauma patients.

OBJECTIVE

To determine the effect of ICP monitoring on survival in pediatric patients with severe head injuries using the National Trauma Data Bank.

DESIGN, SETTING, AND PARTICIPANTS

The National Trauma Data Bank was queried (version 6.2, 2001-2006) for information on patients younger than 17 years admitted to an intensive care unit with blunt traumatic brain injury (TBI), Injury Severity Score (ISS) greater than 9, and Glasgow Coma Scale (GCS) score less than 9. Patients with incomplete medical records and those with intensive care unit length of stay of less than 24 hours were excluded from the study.

MAIN OUTCOMES AND MEASURES

Parametric comparisons (t tests and χ2 as appropriate) were performed to compare patients who received ICP monitoring with those who did not. Stepwise logistic regression methods were used to assess whether ICP monitoring in the presence of other variables (age, sex, ISS, Revised Trauma Score, and GCS score) was associated with survival.

RESULTS

Monitoring of ICP was performed in only 7.7% of patients who met the monitoring criteria recommended by the Brain Trauma Foundation. There were no significant differences in age, sex, or GCS score. After adjustment for admission GCS score, age group, sex, Revised Trauma Score, and injury ISS, ICP monitoring was associated with a reduction in mortality only for patients with a GCS score of 3 (odds ratio, 0.64; 95% CI, 0.43-1.00). Comparison between the 2 groups showed that the ICP monitoring group had a longer hospital length of stay (21.0 days vs 10.4 days; P < .001), longer intensive care unit stay (12.6 vs 6.3 days; P < .001), and more ventilator days (9.2 vs 4.7; P < .001).

CONCLUSIONS AND RELEVANCE

Despite current Brain Trauma Foundation guidelines, ICP monitoring is used infrequently in the pediatric population. The data suggest that there is a small, yet statistically significant, survival advantage in patients who have ICP monitors and a GCS score of 3. However, all patients with ICP monitors experienced longer hospital length of stay, longer intensive care unit stay, and more ventilator days compared with those without ICP monitors. A prospective observational study would be helpful to accurately define the population for whom ICP monitoring is advantageous.

‘Normal’ Vital Signs Belie Occult Hypoperfusion in Geriatric Trauma Patients

Base deficit (BD) and lactic acid (LA) are accepted markers of hypoperfusion and predictors of outcome in the trauma patient and we aim to assess the value of these markers in the triage of the elderly with “normal” vital signs. Patients older than age 65 who presented between 1997 and 2004 but who did not have isolated head injuries were included. Three patient groups were established: normal, occult hypoperfusion (OH), and shock. Outcome measures included mortality, hospital length of stay, intensive care unit length of stay, and discharge disposition. One hundred six patients were included in the analysis and had similar Injury Severity Scores. Mean systolic blood pressure was similar in the normal and OH groups. Forty-two per cent of patients had abnormal BD or LA in the emergency room indicating OH. These patients were more likely to have a longer intensive care unit length of stay (8.6 days vs 3 days; P = 0.01) and were also more likely to be discharged to a nursing facility ( P = 0.03). The trend was toward increased mortality in the OH group. OH is a common finding in elderly trauma patients. Outcomes in these patients are different and more like those presenting in shock.

Routine same-day discharge after acute or interval appendectomy in children: a prospective study

HYPOTHESIS

The outcomes of and parental satisfaction with same-day discharge in children undergoing laparoscopic appendectomy warrant making it the usual and customary pathway.

DESIGN

Prospective cohort study.

SETTING

Tertiary care children's hospital.

PATIENTS

Between July 1, 2010, and March 30, 2011, a total of 207 children were considered for same-day discharge after acute or interval laparoscopic appendectomy. The all-in-one single-incision single-instrument technique was used in 95.7% of children.

INTERVENTIONS

Same-day discharge vs overnight admission.

MAIN OUTCOME MEASURES

Operative details, postoperative length of stay, adverse events, and parental satisfaction.

RESULTS

Of 207 consecutive children undergoing acute (n = 186) or interval (n = 21) appendectomy, 162 (78.3%) were discharged on the day of surgery. The remaining 45 children were admitted overnight because the hour was too late for discharge in 35 (77.8%), medical indications dictated admission in 5 (11.1%), and social reasons required admission in 5 (11.1%). In all the children, oral medication alone was used for postoperative pain. The complication rates were similar in the same-day discharge group (8.0%) and in the admitted group (6.6%), as were the rates of urgent postoperative visits (7.4% vs 4.4%%) and the readmission rates (2.5% vs 2.2%) (P > .05 for all). The same-day discharge group had a reduced postoperative length of stay compared with the admitted group (mean, 5 vs 16 hours, P < .05). At the time of discharge, most parents (87.0%) stated they were happy with the expeditious discharge, whereas 8.0% indicated they felt nervous but were ultimately satisfied. In retrospect, 8 of 162 parents (4.9%) were not sure early discharge was best, but only 1 parent would insist on admission if faced with the situation again.

CONCLUSION

Routine same-day discharge after pediatric appendectomy seems safe, with good parental satisfaction.

Thyroid hormone positively regulates the enterocyte differentiation marker intestinal alkaline phosphatase gene via an atypical response element

Thyroid hormone (T3) is a critical regulator of intestinal epithelial development and homeostasis, but its mechanism of action within the gut is not well understood. We have examined the molecular mechanisms underlying the T3 activation of the enterocyte differentiation marker intestinal alkaline phosphatase (IAP) gene. RT-PCR and Western blotting showed that thyroid hormone receptors TRalpha1 and TRbeta1 were expressed in human colorectal adenocarcinoma Caco-2 cells. Northern blotting detected expression of two IAP transcripts, which were increased approximately 3-fold in response to T3. Transient transfection studies with luciferase reporter plasmids carrying various internal and 5' deletion mutations of the IAP promoter localized a putative thyroid hormone response element (TRE) to a region approximately 620 nucleotides upstream (-620) of the ATG start codon. EMSAs using TRalpha1-retinoid X receptor alpha (RXRalpha) on sequential 5' and 3' single nucleotide deletions defined the TRE between -632 and -612 (5'-TTGAACTCAgccTGAGGTTAC-3'). Compared with the consensus TRE, the IAP-TRE is novel in that it contains an everted repeat of two nonamers (not hexamers) separated by three nucleotides. Neither TRalpha1 nor RXRalpha binds to the IAP-TRE; however, TRbeta1 binds to this TRE with minimal affinity. In the presence of TR and RXRalpha, only the TR-RXRalpha heterodimer binds to the IAP-TRE. Mutagenesis of either nonamer abolishes the biological activity of IAP promoter. We have thus identified a novel response element that appears to mediate the T3-induced activation of the enterocyte differentiation marker, intestinal alkaline phosphatase.

Differential regulation of intestinal alkaline phosphatase gene expression by Cdx1 and Cdx2

We have examined the role that the caudal-related homeobox transcription factors Cdx1 and Cdx2 play in activating the enterocyte differentiation marker gene intestinal alkaline phosphatase (IAP). Human colon cancer Caco-2 cells were transiently transfected with Cdx1 and/or Cdx2, and semiquantitative RT-PCR was used to study the effects on IAP mRNA expression. Transfections with a variety of IAP-luciferase reporter constructs were used to identify a Cdx response element located within the human IAP gene promoter. Protein-DNA interactions were examined by EMSA. Results showed that Cdx1 markedly induced IAP mRNA expression, whereas Cdx2 did not, and, in fact, inhibited the Cdx1 effects. Functional analysis revealed that Cdx1 transactivates (fourfold, P < 0.05) the IAP promoter through a novel Cdx response element (GTTTAGA) located between -2369 and -2375 upstream of the translational start site. EMSA showed that both Cdx1 and Cdx2 could bind to the cis element, but in cotransfection experiments, Cdx2 inhibited the Cdx1 effects by approximately 50%. Thus we have identified a previously unrecognized interaction between two important gut transcription factors, Cdx1 and Cdx2, in the context of IAP gene regulation. Cdx1 activates the IAP gene via a novel cis element, whereas Cdx2 inhibits the Cdx1 effects.

The impact of laparoscopy on the volume of open cases in general surgery training

OBJECTIVE

The purpose of this study was to evaluate the impact of laparoscopy on the volume of open cases in general surgery residency training over the past 10 years.

DESIGN

The Accreditation Council for Graduate Medical Education (ACGME) database (1999-2008), which records all cases (by Current Procedural Terminology code) performed by graduating general surgery trainees, was retrospectively analyzed.

SETTING

ACGME database (1999-2008).

MAIN OUTCOME MEASURES

Trends were compared regarding the average number of the most common laparoscopic and open procedures (colectomy, hernia, and appendectomy) performed by graduating general surgery trainees during the reporting period.

RESULTS

Across all procedures, an increase was noted in laparoscopic approaches with a reciprocal decrease in open cases. The number of open appendectomies decreased by 29% (30.7 to 21.7), whereas the number of laparoscopic appendectomies increased by 278% (8.5 to 32.1). Similarly, open inguinal hernia cases decreased by 12.5% (51.9 to 45.4) and open colectomy cases decreased by 10.4% (48 to 43). Conversely, laparoscopic hernia repair and laparoscopic colectomy increased by 87.5% (7.6 to 15.8) and 550% (2 to 13), respectively.

CONCLUSIONS

In addition to the limitations placed on residency training by other factors (including work hour restrictions), changing practice patterns within the field of general surgery have a significant impact on the exposure of residents to open surgery cases. This trend might have far-reaching implications with regard to the overall competency of graduating residents and raises concerns for the future direction of surgical education.

Clinical pulmonary embolus after gastric bypass surgery

BACKGROUND

Pulmonary embolus (PE) is one of the most common causes of death for patients undergoing gastric bypass surgery. The risk of developing PE has been associated with increased age, greater body mass index (BMI), and chronic venous stasis disease.

METHODS

Between 1998 and 2003, 1225 patients underwent open Roux-en-Y gastric bypass (RYGBP) surgery (258 men and 967 women) for the treatment of morbid obesity and its related disorders. The medical records for morbidly obese patients diagnosed with PE after RYGBP were identified. The presenting signs and symptoms were reviewed, and the known risk factors were analyzed. We compared the age and BMI of these patients with those of a randomly selected RYGBP control group. The Mann-Whitney U test was used to analyze the statistical significance of the results.

RESULTS

During the study period, 11 patients were diagnosed with PE (0.9%). Six patients were men and five were women, for a gender-specific incidence of PE of 2.3% in men and 0.5% in women. The average BMI was 62.5 kg/m(2) in the men and 59.1 kg/m(2) in the women, much greater than in the control group (men 53 kg/m(2) and women 52 kg/m(2); P <0.005 and P <0.05, respectively). All male patients were super-obese (BMI >50 kg/m(2)). The total number of super-obese patients undergoing RYGBP during the study period was 147, for an incidence of PE in super-obese men of 4%. Nine of the 11 patients developed PE after discharge from the hospital within an average of 10 days.

CONCLUSION

The super-obese male patient is at a much greater risk of developing PE than other RYGBP patients (relative risk 4.4). The risk extends to several weeks after discharge. Therefore, extending PE prophylaxis to several weeks after surgery may be warranted.

Acute acalculous cholecystitis (AAC) in the pediatric population associated with Epstein-Barr Virus (EBV) infection. Case report and review of the literature

BACKGROUND

Epstein Barr Virus (EBV) is a ubiquitous herpes virus that persists lifelong in normal humans by colonizing memory B cells. Infection during childhood is usually asymptomatic. Isolated gallbladder wall thickening or hydrops have been reported in patients with EBV infectious mononucleosis. However, acute acalculous cholecystitis is an atypical clinical presentation of primary EBV infection. We present a teenager with acute cholecystitis associated with EBV acute infection. Acute acalculous cholecystitis accounts for 2-15% of all cases of acute cholecystitis. Few cases of acute cholecystitis have been reported during the course of primary EBV infection.

PRESENTATION OF CASE

A 15-year-old female who came to the JDCH ER complaining of 3 days history of mild diffuse abdominal pain associated with two episodes of emesis. She also reports headache as well as a mild cough and low grade subjective fever. Blood test results showed mild leukocytosis with significant elevation in the lymphocytes (59%), High alkaline phosphatase (221 U/I), AST (191 U/I), ALT(221 U/I) and bilirubin (Total 1.8 and direct 1.5). Abdominal US showed a contracted gallbladder with wall thickness and pericholecystic fluid. During hospital stay number 2-3 laboratory work up show a trending up in the bilirubin levels. MRCP was ordered and no abdnormalities were found. At this point Hospital stay number 3 EBV acute infection was suspected. Serum serological studies were subsequently diagnostic for this viral disease. Management was conservative and the patient was discharged asymptomatic on hospital day number six.

Outcomes after Severe Head Injury: A National Trauma Data Bank-Based Comparison of Level I and Level II Trauma Centers

Severely head-injured patients require significant resources across the continuum of care. The objective of this study is to analyze the impact of the level of trauma center designation on the outcome of the severely head-injured patient. The National Trauma Data Bank between 2001 and 2006 (NTDB 6.2) was queried for all patients with isolated traumatic head injury and Glasgow Coma Score (GCS) less than 9. Comparisons between Level I and Level II trauma centers were made reviewing hospital length of stay (LOS), intensive care unit LOS, ventilator days, major complication rate (pulmonary embolism, pneumonia, lower extremity deep vein thrombosis), mortality, and discharge status. Chi-square and Student t tests were used to determine statistical significance defined as P < 0.05. There were 31,736 patients from 258 facilities who met the inclusion criteria during the study period. Level I trauma centers had approximately twice as many patients admissions as Level II centers. However, the severity of injuries and patients’ characteristics identified by the emergency department GCS as well as the probability of survival score showed no difference between Level I and Level II centers. The comparisons between Level I and Level II trauma centers shows that Level II centers are not inferior to Level I in terms of outcomes and complication rate. Level II trauma centers encounter patients with isolated complex head injury less often but with outcomes and complication rates comparable to that of Level I centers. The transport of head-injured patients should not bypass Level II in favor of Level I.

Surgical and anesthetic considerations in histrelin capsule implantation for the treatment of precocious puberty

BACKGROUND

Precocious puberty treatment traditionally meant anxiety-provoking monthly depot injections until the advent of the annually implanted histrelin capsule. This study is the first to evaluate the surgical and anesthetic aspects of histrelin implantation for precocious puberty.

METHODS

All cases from one surgeon at a tertiary pediatric hospital were reviewed for patient age, anesthetic type, technical difficulties, and complications.

RESULTS

From 12/2007 to 3/2013, 114 cases (49% implantations, 25% removals/re-implantations, 25% removals) were performed. Local anesthesia was employed in 100% of non-general anesthesia cases (n=109, 96%), augmented by inhaled N2O in 49%. Five patients (4%) underwent general anesthesia: three neurologically-impaired and two coordinated with scheduled MRIs. Procedural difficulties (n=18, 16%) included implant fracture during removal (n=16/58 removals, 28%). Fracture never occurred during implantation. Three children (3%) suffered complications. One infection was treated with antibiotics, and two implants were removed for systemic allergic reaction. Six children (5%) had unscheduled post-operative checks for pain (n=3, 3%), allergy to elastic dressing (n=2, 2%), or rash (n=1, 1%). Mean charges for general anesthesia were $10,188±1292 versus $528±147 for N2O or local alone (p<0.0001).

CONCLUSION

While histrelin implantation is straightforward, removal presents technical challenges. Local anesthesia, with possible N2O supplementation, is well-tolerated and introduces substantial resource and cost savings.

Initial Experience with Robotic Inguinal Hernia Repair in the Adolescent Population

Purpose: There is no one standard procedure encompassing the needs and differences of the entire pediatric population for inguinal hernia repair (IHR). Several techniques can be used, including open repair, laparoscopic, and robotic-assisted laparoscopic repair. This is a report of a single pediatric hospital's experience performing robotic-assisted IHRs in an adolescent population. Methods: Robotic IHRs performed by the pediatric surgery department were prospectively captured and reviewed. The operation performed was a modified robotic transabdominal preperitoneal approach with ProGrip mesh. Results: Between January 2016 and August 2020, 11 robotic-assisted IHRs occurred. All patients were male, median weight interquartile range (IQR) was 76.6 kg (67.425-90.4 kg) and median age (IQR) was 17 years (17-18.5). All together median (IQR) total operative time was 111 (97.5-126) minutes, median (IQR) total console time was 60 (55.5-75.5) minutes. There were no complications or conversions, with all patients discharged on the day of the operation. Conclusion: This study demonstrates a safe and reliable approach to repairing inguinal hernias using robotics through a small initial case series. Robotic-assisted IHR should be considered a viable technique to optimize the surgical care of adolescents.

Robotic Approach for Median Arcuate Ligament Release in Pediatrics

Background: Median arcuate ligament (MAL) syndrome is a rare cause of chronic abdominal pain in adults and children. Release of the MAL has traditionally been performed open or laparoscopically. There have not been any published cases to our knowledge of robotic-assisted MAL release in pediatric patients. Patients and Methods: Two adolescent patients, aged 12 and 15 years, at our institution underwent robotic-assisted MAL release. The procedure involved dissecting the MAL muscle fibers and overlying scar tissue. Patients stayed inpatient postoperatively overnight and with an average outpatient follow-up of 10 months. Results: Both patients had immediate pain relief postoperatively and at 10-month follow-up had no recurrent symptoms. No complications were associated with the procedure. Conclusion: The increasing role of robotic surgery as a new surgical technique is gaining momentum for many procedures. This new approach for MAL release in the pediatric population was explored by our institution. It was found to be successful, safe, and reproducible for future patients.

Robotic duodeno-duodenostomy creation in a pediatric patient with idiopathic duodenal stricture

Duodenal stenosis is one of the leading causes of duodenal obstruction in the pediatric population, usually diagnosed in newborns and in Down syndrome patients. It has historically been treated with duodeno-duodenostomy, an operation that is now commonly performed laparoscopically. We present a case of a 10-year-old child with a rare chromosomal abnormality who was diagnosed with a duodenal stricture after presenting with failure to thrive and inability to tolerate tube feeds. Duodeno-duodenostomy was performed using the da Vinci^® robot, allowing for improved intra-operative range of motion and control during anastomosis creation, with the same cosmetic benefits of laparoscopic surgery, and subsequent improvement in symptoms postoperatively. This case highlights the utility of robotic surgery in complex operations in the pediatric population.

Case report: Complex retroperitoneal herniation after abdominoperineal resection

INTRODUCTION

We describe the occurrence of a retroperitoneal hernia into the colonic mesentery after abdomoniperineal resection (APR) for rectal cancer.

PRESENTATION OF CASE

A 70year old male presented with complete small bowel obstruction secondary to a complex retroperitoneal herniation. Operative repair was carried out with successful reduction of the hernia contents.

DISCUSSION

A review of the literature is reported concerning retroperitoneal hernia. This occurrence is rare in the adult. Management of the resultant pelvic space after APR is discussed. Closure of the pelvic peritoneum is helpful in avoiding this and other similar complications.

CONCLUSION

We believe this to be the first report of a small bowel obstruction secondary to this unusual hernia circumstance. Although rare, due vigilance and thorough imaging can lead to effective and timely management of this complication.

Conn syndrome and Crohn disease in a pediatric case: an interesting parallel

Conn syndrome is characterized by surreptitious secretion of aldosterone in which patients are found to have hypertension, hypokalemia, and metabolic alkalosis. Although rare, the most common presentation in the pediatric population is bilateral hyperplasia of the adrenal glands as opposed to an adenoma. Crohn disease is part of the spectrum of inflammatory bowel disease, which manifests in children as flare-ups of bloody diarrhea and abdominal pain. The association of concurrent Conn syndrome and Crohn disease has been previously presented in two cases in adults. This is the first pediatric case to be reported in the literature.

Pediatric Single-Incision Robotic Cholecystectomy: A 6-Year Update from a Single Institution

Introduction: In children, gallbladder disease has become more common due to the rise in childhood obesity and subsequent shift in etiology. While the gold standard of surgical management remains a laparoscopic technique, there has been increasing interest in robotic-assisted techniques. The aim of this study is to report a 6-year update on the experience of treating gallbladder disease with robotic-assisted surgery at a single institution. Materials and Methods: A database was created to prospectively collect patient demographic and operative variables at the time of operation from October 2015 to May 2021. Descriptive analysis of select available variables was performed using median and interquartile ranges (IQRs) for all continuous variables. Results: In total, 102 single-incision robotic cholecystectomies and one single-port subtotal cholecystectomy were performed. From available data, 82 (79.6%) patients were female, median weight was 66.25 kg (IQR: 58.09-74.24 kg), and median age was 15 years (IQR: 15-18 years). Median procedure time was 84 minutes (IQR: 70.25-103.5 minutes) and median console time was 41 minutes (IQR: 30-59.5 minutes). The most frequent preoperative diagnosis was symptomatic cholelithiasis (79.6%). One (0.97%) operation was converted from a single-incision robotic approach to open. Conclusion: Single-incision robotic cholecystectomy is a safe and reliable technique for the treatment of gallbladder disease in the adolescent population.

Recombinant factor VIIa: hemostatic adjunct in the coagulopathic burn patient

INTRODUCTION

Recombinant factor VIIa (rFVIIa; NovoSeven) is well recognized as an effective hemostatic agent in the management and prophylaxis of patients with hemophilia. We report here the successful use of rFVIIa in a coagulopathic burn patient.

METHODS

A 63-year-old man was admitted with significant upper-body burns in a total body surface area of 60%. Initial management included early intubation and escharotomies, with subsequent admission to the burn unit. Fascial excision was carried out with allograft placement. During a complicated hospital course, decline in platelet function was noted and was associated with the development of a generalized coagulopathy with elevated international normalized ratio. Following a routine follow-up debridement and autografting, extensive bleeding was noted from donor sites. A period of increasing hemodynamic instability followed in the burn unit, with serial hematocrit measurements pointing toward ongoing bleeding from the surgical sites. Following administration of significant amounts of blood product, it was decided to administer rFVIIa per pharmacy protocol.

RESULTS

Within 4 hours of administration of rFVIIa, the patient was noted to be hemodynamically stable with unchanging serial hematocrit measurements. Hemostasis was attributed to the use of rFVIIa with prior administration of platelets.

CONCLUSIONS

Our case demonstrates the successful use of rFVIIa in the severely coagulopathic burn patient.

Prenatal Recognition of Hepatopulmonary Fusion in Right-Sided Congenital Diaphragmatic Hernia for Successful Operative Planning

INTRODUCTION

Hepatopulmonary fusion (HPF) is a rare anomaly specifically associated with right-sided congenital diaphragmatic hernia (CDH). Fewer than 50 cases of HPF have been reported, most at the time of surgery or postmortem with an associated high morbidity and mortality rate. Prenatal diagnosis and optimal management of these rare cases have not been established.

CASE PRESENTATION

We present a case of HPF diagnosed prenatally by fetal ultrasound and magnetic resonance imaging allowing postnatal and intraoperative planning leading to successful HPF separation and repair of the CDH.

DISCUSSION

The prenatal recognition allowed the use of preoperative computed tomography angiogram and right cardiac catheterization to plan the surgical approach. Intraoperative ultrasound confirmed abnormal vasculature associated with the HPF facilitating a successful complete HPF separation and CDH repair was performed. The patient survived and continues to do well on long-term follow-up. Prenatal recognition may help reduce the high morbidity and mortality associated with HPF.

'Normal' vital signs belie occult hypoperfusion in geriatric trauma patients

Base deficit (BD) and lactic acid (LA) are accepted markers of hypoperfusion and predictors of outcome in the trauma patient and we aim to assess the value of these markers in the triage of the elderly with "normal" vital signs. Patients older than age 65 who presented between 1997 and 2004 but who did not have isolated head injuries were included. Three patient groups were established: normal, occult hypoperfusion (OH), and shock. Outcome measures included mortality, hospital length of stay, intensive care unit length of stay, and discharge disposition. One hundred six patients were included in the analysis and had similar Injury Severity Scores. Mean systolic blood pressure was similar in the normal and OH groups. Forty-two per cent of patients had abnormal BD or LA in the emergency room indicating OH. These patients were more likely to have a longer intensive care unit length of stay (8.6 days vs. 3 days; P = 0.01) and were also more likely to be discharged to a nursing facility (P = 0.03). The trend was toward increased mortality in the OH group. OH is a common finding in elderly trauma patients. Outcomes in these patients are different and more like those presenting in shock.

Outcomes after severe head injury: a National Trauma Data Bank-based comparison of Level I and Level II trauma centers

Severely head-injured patients require significant resources across the continuum of care. The objective of this study is to analyze the impact of the level of trauma center designation on the outcome of the severely head-injured patient. The National Trauma Data Bank between 2001 and 2006 (NTDB 6.2) was queried for all patients with isolated traumatic head injury and Glasgow Coma Score (GCS) less than 9. Comparisons between Level I and Level II trauma centers were made reviewing hospital length of stay (LOS), intensive care unit LOS, ventilator days, major complication rate (pulmonary embolism, pneumonia, lower extremity deep vein thrombosis), mortality, and discharge status. Chi-square and Student t tests were used to determine statistical significance defined as P < 0.05. There were 31,736 patients from 258 facilities who met the inclusion criteria during the study period. Level I trauma centers had approximately twice as many patients admissions as Level II centers. However, the severity of injuries and patients' characteristics identified by the emergency department GCS as well as the probability of survival score showed no difference between Level I and Level II centers. The comparisons between Level I and Level II trauma centers shows that Level II centers are not inferior to Level I in terms of outcomes and complication rate. Level II trauma centers encounter patients with isolated complex head injury less often but with outcomes and complication rates comparable to that of Level I centers. The transport of head-injured patients should not bypass Level II in favor of Level I.