Faculty Bibliography

BACKGROUND:The 2010 Haiti earthquake severely strained local healthcare infrastructure. In the wake of this healthcare crisis, international organizations provided volunteer support. Studies demonstrate that this support improved short-term recovery; however, it is unclear how long-term surgical capacity has changed and what role volunteer surgical relief efforts have played. Our goal was to investigate the role of international surgical volunteers in the increase of surgical capacity following the 2010 Haiti earthquake. METHODS:We retrospectively analyzed the operative reports of 3208 patients at a general, trauma and critical care hospital in Port-au-Prince from June 2010 through December 2013. We collected data on patient demographics and operation subspecialty. Surgeons and anesthesiologists were categorized by subspecialty training and as local healthcare providers or international volunteers. We performed analysis of variance to detect changes in surgical capacity over time and to estimate the role volunteers play in these changes. RESULTS:Overall number of monthly operations increased over the 2.5 years post-earthquake. The percentage of orthopedic operations declined while the percentage of other subspecialty operations increased (p = 0.0003). The percentage of operations performed by international volunteer surgeons did not change (p = 0.51); however, the percentage of operations staffed by volunteer anesthesiologists declined (p = 0.058). The percentage of operations performed by matching specialty- and subspecialty-trained international volunteers has not changed (p = 0.54). CONCLUSIONS:Haitian post-earthquake local and overall surgical capacity has steadily increased, particularly for provision of subspecialty operations. Surgical volunteers have played a consistent role in the recovery of surgical capacity. An increased focus on access to surgical services and resource-allocation for long-term surgical efforts particularly in the realm of subspecialty surgery may lead to full recovery of surgical capacity after a large and devastating natural disaster.

INTRODUCTION/BACKGROUND:Prior research has demonstrated that platelet count and inflammation are dominant contributors to hypercoagulability. Our objective is to determine whether elevated platelet count and systemic inflammatory response syndrome (SIRS) have an association with the development of venous thromboembolism (VTE) in hospitalized patients with a high clinical index of suspicion for thromboembolic disease. METHODS:We performed a retrospective medical record review of 844 medical and surgical patients with suspected VTE hospitalized from July 2012 to May 2013 who underwent screening by venous duplex and computed tomography pulmonary angiogram. For our purposes, thrombocytosis was arbitrarily defined as platelet count ≥250×10(9)/L. RESULTS:Venous thromboembolic disease was detected in 229 patients (25.9%). Thrombocytosis was present in 389 patients (44%) and SIRS was present in 203 patients (23%) around the time of imaging. Thrombocytosis and SIRS were positively correlated with VTE (P<0.001). There was no correlation between thrombocytosis and SIRS. Multivariate analysis revealed that SIRS (odds ratio 1.91, 95% confidence interval 1.36-2.68, P<0.001) and thrombocytosis (odds ration 1.67, 95% confidence interval 1.23-2.26, P=0.001) were independently associated with VTE. CONCLUSION/CONCLUSIONS:Patients at high risk for VTE should be routinely assessed for thrombocytosis (≥250×10(9)/L) and SIRS; if either is present, consideration for empiric anticoagulation should be given while diagnostic imaging is undertaken.

BACKGROUND:Prevention of secondary brain injury is a key component of acute management of patients with severe traumatic brain injury (TBI). Haemoglobin concentration may have an impact on optimization of cerebral oxygenation. Patients with TBI may best be served by an organized trauma service. The objective is to determine if haemoglobin concentration or dedicated trauma admission has an impact on outcomes after severe TBI. METHODS:This study retrospectively analysed consecutive patients with severe TBI admitted to a level-I trauma centre over 3 years. Patients <16 years-old and with length of stay (LOS) <24 hours were excluded. Data were collected on demographics; injury severity; LOS; admission service; survival to discharge; and haemoglobin levels from hospital days 1-7. Data were also collected on number of transfusions of packed red blood cells. The sample was stratified based on admission service and survival to discharge. RESULTS:Of 147 patients (age = 54.1 ± 3.7 years), overall mortality rate was 15.4% (n = 23). Overall, non-survivors had lower daily and 7-day mean haemoglobin levels (10.7 ± 0.9 vs. 12.9 ± 0.4 g dL(-1), p < 0.001). Non-surgical admissions had lower haemoglobin levels and a higher mortality rate (28.9% vs. 12.2%, p < 0.001) compared to dedicated trauma admissions. CONCLUSIONS:Among patients with severe TBI, higher haemoglobin levels and maintenance as a dedicated trauma admission are associated with higher survival to discharge.

INTRODUCTION/BACKGROUND:Colonic atresia and anorectal malformation are rare congenital anomalies individually. Few reports of the conditions combined in a single patient have been published in the literature. Neither colonic atresia, anorectal malformation or a combination of the disorders has previously been reported in the Haitian population. CASE PRESENTATION/METHODS:A 5-day-old female presented with feculent emesis, failure to pass stool since birth and an imperforate and stenotic anus. Exploratory laparotomy revealed colorectal atresia distal to a malformed cecum and a Wingspread low subtype anorectal malformation without any associated urogenital fistulae. Temporizing percutaneous ileal drainage was followed by second-stage anal perforation and dilation, ileal J-pouch and pull through. DISCUSSION/CONCLUSIONS:This is the first reported case of colonic atresia, anorectal malformation or the combination of the disorders among the Haitian population and one of only a handful of such cases reported worldwide. Although vascular accidents in utero have been implicated as the etiology of colonic atresia, simultaneous presence of anorectal malformation suggests a multifactorial cause. Investigation for multisystem abnormalities is warranted. Two-staged operative correction is considered the best treatment; however, long-term postoperative outcomes are uncertain. CONCLUSION/CONCLUSIONS:The coexistence of colonic atresia and anorectal malformation is a very rare occurrence and presents unique clinical and operative challenges. Investigation for additional congenital abnormalities is appropriate, and although two-stage operative correction is considered the best treatment, long-term outcomes are uncertain.

INTRODUCTION/BACKGROUND:The laparoscopic approach is an increasingly popular option for ventral hernia repair. In the wake of this new technology, unexpected complications have been reported. CASE PRESENTATION/METHODS:We present the case of a patient who developed a liver laceration and hemorrhage after a mesh tacking device partially dislodged subsequent to ventral hernia repair. The patient underwent exploratory laparotomy, liver hemostasis and removal of the offending tack. DISCUSSION/CONCLUSIONS:Our patient partially dislodged a mesh tacking device likely after violent coughing during a bout of pneumonia. The exposed blade caused a liver laceration and hemorrhage. Few other unexpected complications of the use of mesh tacking devices have been noted in the literature. Tackless hernia repair has also been described. CONCLUSION/CONCLUSIONS:Laparoscopic ventral hernia repair with tacks may have unexpected complications of which the surgeon should be aware and advise patients. Our patient developed a liver laceration and symptomatic hemorrhage after partially dislodging a hernia mesh tack. Further research into tackless hernia repair may be beneficial. A low long-term recurrence rate would demonstrate if tackless hernia repair is a viable option.

CONTEXT: Postoperative ileus is a known complication after abdominal operations, and the clinical efficacy of osteopathic manipulative treatment (OMT) in postoperative surgical patients has seldom been the subject of research. OBJECTIVE: To determine whether there is a relationship between postoperative use of OMT and postoperative outcomes in gastrointestinal surgical patients, including time to flatus, clear liquid diet, and bowel movement and postoperative hospital length of stay (LOS). DESIGN: A retrospective cohort study. SETTING: A 350-bed urban community hospital with an osteopathic residency program in general surgery. PATIENTS: Fifty-five patients who underwent a major gastrointestinal operation, who did not die, and who had complete perioperative medical records. MAIN OUTCOME MEASURES: We evaluated demographic data; American Society of Anesthesiologists physical status class; preoperative comorbid conditions; postoperative complications; postoperative time to flatus, clear liquid diet, and bowel movement; postoperative hospital LOS; electrolyte abnormalities; and types of narcotics used. RESULTS: Of the 55 patients who met the study criteria, 17 had received postoperative OMT and 38 had not. The mean age was 60.3 years in the OMT group and 62.1 years in the non-OMT group (P=.70). The 2 groups were similar in terms of American Society of Anesthesiologists class, number of comorbid conditions and of postoperative complications, presence of electrolyte abnormalities, and narcotic use. The time to bowel movement and to clear liquid diet did not differ significantly between the groups. The mean (standard deviation [SD]) time to flatus was 4.7 (0.4) days in the non-OMT group and 3.1 (0.6) days in the OMT group (P=.035). The mean (SD) postoperative hospital LOS was also reduced significantly with OMT, from 11.5 (1.0) days in the non-OMT group to 6.1 (1.7) days in the OMT group (P=.006). CONCLUSION: Osteopathic manipulative treatment applied after a major gastrointestinal operation is associated with decreased time to flatus and decreased postoperative hospital LOS.