Faculty Bibliography

PURPOSE/OBJECTIVE:Morbid obesity is associated with urinary incontinence (UI). The study purpose was to determine the prevalence of fecal incontinence (FI), its associated risk factors, and its impact on quality of life (QOL) in morbidly obese women. MATERIALS AND METHODS/METHODS:A questionnaire-based study on morbidly obese women [body mass index (BMI)>or=35 m/kg2], attending a bariatric surgery seminar, was conducted. Data included demographics, past medical, surgical and obstetric history, and obesity-related co-morbidities. Patients who reported of FI, completed the Cleveland Clinic Foundation Fecal Incontinence scale (CCF-FI) and the Fecal Incontinence Quality of Life scale (FIQL). RESULTS:Participants included 256 women [median age 45 years (19-70)] and mean BMI of 49.3+/-9.4 m/kg2. FI was reported in 63%. History of obstetric injury (OR: 2.4, 95% CI: 1.33-4.3; p<0.001) and UI (OR: 1.2, 95% CI: 1.1-1.4; p<0.001) were significantly associated with FI. There was no association with age, BMI, parity, and presence of diabetes or hypertension. Median CCF-FI score was 7 (1-20); 34.5% scored>or=10. Incontinence for gas was the most frequent type (87%) of FI, followed by incontinence for liquids (80%), which also had the highest impact on QOL (p<0.01). Mean FIQL scores were >3 for all four domains studied. CCF-FI scores were significantly correlated with FIQL scores in all domains (p=0.02). COMMENT/CONCLUSIONS:The prevalence of FI among morbidly obese women may be much higher than the rates reported in the general population. FI has adverse effects on QOL. Its correlation with UI suggests that morbid obesity may pose a risk of global pelvic floor dysfunction.

BACKGROUND AND PURPOSE/OBJECTIVE:The scarcity of organs for transplantation has led to aggressive pretransplant evaluations. Many younger kidney transplant patients with end-stage renal disease, who would be ordinarily at average risk for colorectal cancer, undergo screening colonoscopy as part of this evaluation. The purpose of this study was to determine the prevalence of colorectal neoplasia in patients with end-stage renal disease who are potential transplant candidates. MATERIALS AND METHODS/METHODS:We performed a retrospective chart review analysis on 57 kidney transplant candidates who underwent pretransplant screening colonoscopy between August 1999 and December 2004. The control group was comprised of 60 age- and gender-matched subjects without end-stage renal disease who underwent routine screening colonoscopy. RESULTS:The prevalence of polyps in end-stage renal disease patients was 37 vs 22% in the control group (p=0.07, not significant). None of the risk factors studied were found to predict the presence of polyps in the study group. CONCLUSION/CONCLUSIONS:These results suggest that screening guidelines for colorectal cancer for the general population should be adequate for potential kidney transplant recipients.

PURPOSE/OBJECTIVE:This study was designed to determine the impact of excess body mass on the prevalence of pelvic floor disorders in morbidly obese females. METHODS:A total of 358 morbidly obese females (body mass index (BMI) >or= 35 kg/m(2)) completed two validated, condition-specific, quality of life questionnaires of pelvic floor dysfunction, which assessed stress/impact in three main domains of pelvic floor disorders: pelvic organ prolapse, colorectal-anal, and urogenital incontinence. Prevalence and severity scores in the study population were compared with data from 37 age-matched nonobese controls (BMI <or= 35 kg/m(2)). RESULTS:Mean age was 43 +/- 11 years vs. 42 +/- 12 years, and mean BMI was 50 +/- 10 kg/m(2) vs. 26 +/- 4 kg/m(2) (p = 0.02) in the study and control groups, respectively. Parity and past obstetric history were similar between the groups. Pelvic floor disorders were prevalent in 91 percent of the morbidly obese females compared with 22 percent in the control group (p < 0.001). Scores were statistically significantly higher in the study group for all studied stress/impact domains (p < 0.001 and p = 0.001, respectively). Further stratifications in the study group revealed a significant impact on pelvic floor disorders with increased age (p < 0.003 and p < 0.009 for stress/impact mean scores, respectively) and the presence of other comorbidities (p< 0.008, p < 0.03 for stress/impact prevalence, respectively). Additional increases in BMI > 35 kg/m(2) did not show increased adverse impacts on pelvic floor disorders symptoms. CONCLUSION/CONCLUSIONS:More than 90 percent of morbidly obese females experience some degree of pelvic floor disorders, and 50 percent of these females report that symptoms adversely impact quality of life. In morbidly obese females, obesity is as important as obstetric history in predicting pelvic floor dysfunction.

BACKGROUND:Tube thoracostomy is usually sufficient treatment for traumatic hemothorax. Occasionally, significant residual collections remain undrained. Open thoracotomy and video-assisted thoracoscopic surgery (VATS) have been used to manage undrained traumatic hemothoraces (UTHs). Both techniques are invasive and harbor risks. More recently, intrapleural administration of thrombolytic agents (streptokinase and urokinase) has been reported as an effective nonoperative treatment of residual collections caused by a variety of diseases. The role of intrapleural thrombolysis (IT) for the treatment of an UTH is inadequately explored. METHODS:Patients with an UTH, defined as more than 300 mL of intrathoracic blood estimated by computed tomographic scan on the third day after chest tube insertion, were followed prospectively for 16 months. IT was instituted according to a standardized protocol using streptokinase or urokinase. IT effectiveness, defined by the incidence of successful resolution of the UTH, and IT safety, defined by the incidence of uncomplicated therapy, was calculated. RESULTS:Of 203 patients with a traumatic hemothorax, managed by tube thoracostomy, 25 (12.3%) developed an UTH. Successful resolution of the UTH was achieved in 23 (92%) patients within 3.4+/-1.4 days. No bleeding or other significant complications related to IT were recorded. CONCLUSIONS:IT should be the initial treatment of choice for the management of an UTH.

BACKGROUND:Superior mesenteric vein injuries are rare and incur high mortality. Given their low incidence, little data exist delineating indications for when to institute primary repair versus ligation. The purposes of this study are to review our institutional experience, to determine the additive effect on mortality of associated vascular injuries, to correlate mortality with the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury and to examine and define the indications and outcomes for primary repair versus ligation. MATERIAL/METHODS:Retrospective 156 months study (January 1992 through December 2004) in a large Level I urban trauma center of all patients admitted with superior mesenteric vein injuries. Patients were stratified, according to surgical technique employed to deal with their injuries, into those undergoing primary repair versus ligation to determine outcomes and define the surgical indications of these methods. The main outcome measure was overall survival. Cases of survival were stratified according to surgical method: primary repair versus ligation. RESULTS:There were 51 patients with a mean Injury Severity Score of 25 +/- 12. Mechanism of injury was penetrating for 38 (76%), blunt for 13 (24%), and patients undergoing emergency department thoracotomy for 4 (8%). Surgical management was ligation for 30 (59%), primary repair for 16 (31%), and 5 (10%) patients were exsanguinated before repair. The overall survival rate was 24/50 (47%). The survival rate excluding patients undergoing emergency department thoracotomy was 51%. The survival rate excluding patients that sustained greater than 3 to 4 associated vessels injured was 65%. The survival rates of patients with superior mesenteric vein and superior mesenteric artery was 55% and superior mesenteric vein and portal vein (PV) was 40%. The survival rate of patients with isolated superior mesenteric vein injuries was 55%. Mortality stratified to AAST-OIS grade III, 44%; grade IV, 42%; and grade V, 42%. Survival rates stratified to method of management consisted of primary repair (60%) versus ligation (40%). CONCLUSIONS:SMV injuries are highly lethal. Multiple associated vessel injuries increase mortality. Mortality correlates well with the American Association for the Surgery of Trauma-Organ Injury Scale for abdominal vascular injuries. Patients undergoing primary repair have higher survival rates (63%) and lesser numbers of associated vascular and nonvascular injuries; whereas those undergoing ligation have a smaller survival rate (40%) and higher number of associated vascular and nonvascular injuries. Ligation appears to be safe and should be selected for hemodynamically unstable patients with a large number of associated injuries.

BACKGROUND:Femoral vessel injuries are the most common vascular injuries treated in a Level I trauma center. No studies have identified risk factors for survival and complications. STUDY DESIGN/METHODS:We performed a retrospective, 132-month study that included univariate and multivariate analyses. RESULTS:We studied 204 patients with 298 vessel injuries: 204 were arterial, 94 were venous. Mean age (+/- SD) was 29+/-13 years and mean Injury Severity Score (+/- SD) was 17+/-8. There were 176 (86%) penetrating injuries and 28 (14%) blunt injuries. Arterial repairs included: reverse saphenous vein graft bypass, 108 (53%); primary repair, 53 (26%); PTFE, 21 (10.2%); ligation, 13 (6.4%); and vein patch, 9 (4.4%). Venous repairs included: ligation, 49 (52%); primary repair, 41 (44%); and bypass, 4 (4%). Fasciotomies included: calf, 56 (27%); thigh, 25 (12%); traumatic amputations, 6 (3%); and delayed amputations, 0. Overall survival rate was 91% (186 of 204), and adjusted survival was 95% (excluding emergency department thoracotomy deaths). There were 1 or more complications in 47 (23%), including wound infection, 31 (15%); venous thrombosis, 6 (3%); bleeding, 5 (2.5%); ARDS, 4 (2%); and arterial thrombosis, 1 (0.5%). Predictors of mortality were age>45 years, Injury Severity Score>25, common femoral artery injury, associated venous and abdominal injury, hypotension, hypothermia, and acidosis; coagulopathy in the operating room and the need for PTFE repair also predicted outcomes. Predictors of postoperative complications were intraoperative hypotension, arterial intimal injury, bony fracture, and thoracic injury. CONCLUSIONS:Although survival and limb salvage rates are high for femoral vessel injuries, these injuries incur high complication rates. Independent predictors for mortality are: Injury Severity Score > 25, Glasgow Coma Scale 28, presence of coagulopathy in the operating room, presence of two or more vascular signs, and age > 45 years.

One of the most recent innovations coalescing computer technology and medical care is the development of integrated medical component technology coupled with a computer system. One such example is the patient transport system known as the Life Support for Trauma and Transport (LSTAT). LSTAT is a self-contained stretcher-based intensive care unit designed by the United States Army to provide care for critically injured patients during transport and in remote settings where resources are limited. It contains conventional medical equipment that has been reduced in size and integrated into a single platform. This article presents the latest technology applied to the field of medicine, which should not be limited to patients injured during warfare but should also be used to assist the injured civilian population who need transport from remote settings to urban trauma centers.

BACKGROUND:Current methods of posttraumatic thromboprophylaxis (heparins and sequential compression devices) are inadequate. New methods should be tested. Muscle electrostimulation (MEST) has been used over the years with mixed-but predominantly encouraging-results for a variety of conditions, including prevention of deep venous thrombosis (DVT). It has not been tested in multiple trauma patients. METHODS:Trauma patients with Injury Severity Score higher than 9 who were admitted to the intensive care unit and had a contraindication for prophylactic heparinization were randomized to groups MEST and control. MEST patients received 30-minute MEST sessions twice daily for 7 to 14 days. Venous flow velocity and venous diameter were measured by duplex venous scan. Venography-or, if not available, duplex-was used to evaluate the presence of proximal and peripheral DVT between days 7 and 15. RESULTS:After exclusions, 26 MEST and 21 control patients completed the study and received outcome evaluation by venography (25) or duplex (22). Three patients in each group developed proximal DVT (11.5% vs 14%, P = .79), and an additional 4 (15%) MEST group and 3 (14%) control group patients developed peripheral DVT ( P = .96). There was no difference in venous flow velocity or venous diameter between the groups. CONCLUSIONS:MEST was not effective in decreasing DVT rates in major trauma patients.