Rectal Injury After Foreign Body Insertion: Secondary Analysis From the AAST Contemporary Management of Rectal Injuries Study Group

BACKGROUND

Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion.

METHODS

Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative).

RESULTS

After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management.

CONCLUSIONS

Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.

Can a teaching assistant experience in a surgical anatomy course influence the learning curve for nontechnical skill development for surgical residents?

The foundation upon which surgical residents are trained to work comprises more than just critical cognitive, clinical, and technical skill. In an environment where the synchronous application of expertise is vital to patient outcomes, the expectation for optimal functioning within a multidisciplinary team is extremely high. Studies have shown that for most residents, one of the most difficult milestones in the path to achieving professional expertise in a surgical career is overcoming the learning curve. This view point commentary provides a reflection from the two senior medical students who have participated in the Student-as-Teacher program developed by the Department of Anatomy at Mayo Clinic, designed to prepare students for their teaching assistant (TA) role in anatomy courses. Both students participated as TAs in a six week surgical anatomy course for surgical first assistant students offered by the School of Health Sciences at Mayo Clinic. Development of teaching skills, nontechnical leadership, communication, and assessment skills, are discussed in relation to their benefits in preparing senior medical students for surgical residency.

Risk Factors for Failure of Splenic Angioembolization: A Multicenter Study of Level I Trauma Centers

BACKGROUND

Angioembolization (AE) is an adjunct to nonoperative management (NOM) of splenic injuries. We hypothesize that failure of AE is associated with blood transfusion, grade of injury, and technique of AE.

METHODS

We performed a retrospective (2010-2017) multicenter study (nine Level I trauma centers) of adult trauma patients with splenic injuries who underwent splenic AE. Variables included patient physiology, injury grade, transfusion requirement, and embolization technique. The primary outcome was NOM failure requiring splenectomy. Secondary outcomes were mortality, complications, and length of stay.

RESULTS

A total of 409 patients met inclusion criteria; only 33 patients (8%) required delayed splenectomy. Patients who failed received more blood in the first 24 h (P = 0.009) and more often received massive transfusion (P = 0.01). There was no difference in failure rates for grade of injury, contrast blush on computed tomography, and branch embolized. After logistic regression, transfusion in the first 24 h was independently associated with failure of NOM (P = 0.02). Patients who failed NOM had more complications (P = 0.002) and spent more days in the intensive care unit (P < 0.0001), on the ventilator (P = 0.0001), and in the hospital (P < 0.0001). Patients who failed NOM had a higher mortality (15% versus 3%, P = 0.007), and delayed splenectomy was independently associated with mortality (odds ratio, 4.2; 95% confidence interval, 1.2-14.7; P = 0.03).

CONCLUSIONS

AE for splenic injury leads to effective NOM in 92% of patients. Transfusion in the first 24 h is independently associated with failure of NOM. Patients who required a delayed splenectomy suffered more complications and had higher hospital length of stay. Failure of NOM is independently associated with a fourfold increase in mortality.

Bilateral popliteal artery injury: Lessons learned

Popliteal artery trauma is reported to have the highest rates of limb loss in peripheral vascular injuries. It can be inferred that morbidity associated with bilateral popliteal artery trauma is worse. However, bilateral popliteal artery injuries are sparsely reported in literature and as such management options are not well defined. Despite the paucity of reported cases, a systematic and deliberate approach to these devastating injuries may result in reproducible limb salvage. We hereby use our case report as a provocateur to this conundrum. Consideration should be given to the utilization of surgical shunts or a two-surgical team and limb salvage attempted till proving the neurovascular bundle irreparable. Arterial grafts should be part of the surgeon's armamentarium. In massive hard to control hemorrhage, tourniquets or resuscitative endovascular occlusion devices (REBOA) may prove lifesaving. Larger studies are needed to define contemporary management and derive management guidelines.

Appendiceal malakoplakia masquerading as a cecal mass

Appendiceal malakoplakia masquerading as a cecal mass is uniquely rare. The presence of an infiltrate of granular eosinophilic macrophages containing Michaelis–Gutmann bodies on histopathology is pathognomonic of malakoplakia. Cutaneous, gastrointestinal and most commonly urogenital malakoplakia is reported in association with an immunocompromised state, infectious, inflammatory and neoplastic processes. Presentation varies from microscopic disease to plaques, nodules, polypoid lesions and small masses. However, a cecal mass postea proven appendiceal malakoplakia deserves special attention. We could not find similar case reports in the English literature. The pathogenesis of malakoplakia is poorly understood, and it is unclear if it is a harbinger of malignancy, a precursor lesion or an inflammatory marker. In the setting of a dominant appendiceal mass, post-treatment endoscopic and tumor marker surveillance is paramount but, however, undefined in contemporary literature.

Non-operative management of iatrogenic colonic perforation after percutaneous cholecystotomy

The management of iatrogenic colonic perforation encountered during percutaneous cholecystotomy tube placement is not well reported. It is unclear as to whether an operative versus a conservative approach is ideal for this complication. We therefore present our case report to spur a discussion on patient selection, interval follow-up and call for future studies regarding this uncommon complication.

Discordance Between Conventional and Detailed Lymph Node Analysis in Resected, Node-negative Pancreatic or Ampullary Adenocarcinomas and Association With Adverse Survival Outcomes: A Single-institution Analysis

OBJECTIVE

To assess the frequency of occult metastases (OM) in patients with resected pancreatic ductal adenocarcinoma (PDAC) or ampullary adenocarcinoma (AA) discovered on detailed pathologic examination on lymph nodes (LNs) previously considered negative by conventional analysis and to examine the association between OM and overall survival (OS).

BACKGROUND

Poor prognosis of patients with no pathologic evidence of LN metastases may be due to OM that is not detected on conventional LN analysis.

METHODS

Patients with LN-negative resected PDAC or AA (2010-2020) were identified from our institutional database. Original hematoxylin and eosin ( H and E ) slides were reanalyzed. In addition, selected LN were analyzed by H and E (3 sections/LN) and pan-cytokeratin (AE1-AE3/PCK26) immunohistochemistry.

RESULTS

A total of 598 LNs from 74 LN-negative patients were reexamined. Nineteen patients (25.7%) had OM; 9 (47.4%) were found with immunohistochemistry but not on H and E . The number of positive LNs ranged from 1 to 3. No clinicodemographic, pathologic, or treatment-related factors were associated with OM. On conventional LN analysis, 3/19 patients (15.8%) had stage IA, 9/34 (26.5%) had stage IB, and 7/19 (36.8%) had stage IIA. On detailed LN analysis, 11/19 patients (57.9%) were upstaged to IIB, whereas 8/19 (42.1%) had isolated tumor cells only (N0i+). OM was associated with shorter OS (median OS: 22.3 vs 50.5 months; hazard ratio=3.95, 95% CI: 1.58-9.86).

CONCLUSIONS

There is a 26% discordance rate between conventional and detailed LN pathologic analysis in resected PDAC and AA. The presence of OM is associated with shorter OS.

A community survey of traditional medical practitioners in high density suburbs of Harare

Traditional medical practitioners (TMP) are an important part of the health system in Zimbabwe. The objective of this study was to determine, in the study area, their numbers, sociodemographic characteristics and clinical practice. A cross sectional community survey was conducted in two high density suburbs in Harare, Zimbabwe. A sampling frame of TMP was defined by means of a three stage community census (n = 189). A random stratified sample (n = 110) was interviewed with a semi-structured interview. Nearly half the TMP were not registered with formal organizations. Prophets were more likely to be Zimbabwean, Shona speaking, better educated, to have entered practice at a younger age, had fewer years of experience and charged less for consultations. Many TMP reported busy attendance at their clinics in the evenings or on weekends, but on average, most TMP see few patients. Few TMP specialised in physical disorders. Almost two thirds referred patients to formal medical services and most TMP wished to have greater collaboration with biomedical services.

Extended antibiotic therapy is associated with a lower rate of clinically relevant postoperative pancreatic fistula after pancreatoduodenectomy in intermediate- and high-risk patients: A single-institution analysis

BACKGROUND

Clinically relevant postoperative pancreatic fistula remains a common complication after pancreatoduodenectomy. The fistula risk score is a validated tool to predict the risk of clinically relevant postoperative pancreatic fistula. To mitigate complications, we have implemented an extended antibiotic pathway for patients at increased risk of clinically relevant postoperative pancreatic fistula (fistula risk score ≥3). We report outcomes after pancreatoduodenectomy in patients at increased risk for clinically relevant postoperative pancreatic fistula who received extended antibiotic therapy compared to those who received standard perioperative antibiotics (single dose before incision).

METHODS

Single-institution analysis of 87 patients who underwent elective pancreatoduodenectomy (2018-2022) with soft gland texture and fistula risk score ≥3 and were treated with (n = 34) or without (n = 53) 10 days of broad-spectrum antibiotics (piperacillin/tazobactam converted to amoxicillin/clavulanic acid at discharge) after surgery. Associations between extended antibiotics and postoperative outcomes were analyzed.

RESULTS

Baseline clinicodemographic factors were similar between cohorts. Patients who received extended antibiotics had shorter index days (6 vs 8 days, P = .004) and 90-day composite length of stay (8.5 vs 12 days, P = .018). Patients who received extended antibiotics had lower rates of clinically relevant postoperative pancreatic fistula (11.8% vs 37.7%; odds ratio = 0.17, 95% confidence interval: 0.04-0.68), wound infections (8.8% vs 30.2%; odds ratio = 0.08, 95% confidence interval: 0.01-0.50), organ space infections (14.7% vs 43.4%; odds ratio = 0.15, 95% confidence interval: 0.04-0.52), and image-guided drain placement (8.8% vs 34.0%; odds ratio = 0.15, 95% confidence interval: 0.04-0.62). There were no Clostridium difficile infections in the extended antibiotic group.

CONCLUSION

Extended antibiotic therapy is associated with a lower rate of clinically relevant postoperative pancreatic fistula and associated complications after pancreatoduodenectomy in patients with a fistula risk score ≥3. These results form the basis of a randomized controlled trial (NCT05753735).