tas803briefreports 307..320

6 downloads 163748 Views 539KB Size Report
The Accreditation Council for Graduate Medical Ed- ucation (ACGME) ... cifically addresses the program's processes for resident grievances, the results of ..... Fort Lauderdale, Florida ... 4. Falyar CR. Using transcranial Doppler sonography.
Brief Reports Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online under ‘‘Instructions for Authors’’.) They should be no more than 4 double-spaced pages with no Abstract or sub-headings, with a maximum of four (4) references. If figures are included, they should be limited to two (2). The cost of printing color figures is the responsibility of the author. In general, authors of case reports should use the Brief Report format.

Addressing Trainees’ Concerns through a Resident Advocacy Committee The Accreditation Council for Graduate Medical Education (ACGME) requires that procedures be in place to address residents’ concerns and grievances in a confidential manner with assurances that substantive problems are addressed in a definitive manner by the residency and its sponsoring institution.1, 2 In their annual Residents and Fellows Surveys, the ACGME specifically addresses the program’s processes for resident grievances, the results of which are provided to the residency program director. Procedures may not effectively address problems with the program because they may not be applied or not accessible to the trainees. The messenger may be reluctant to let his or her observations be known because of fear of retribution and retaliation arising from unequal positions of power. Recently the results from the Residents Survey from our program reflected a significant problem in our processes to address resident grievances in a confidential and effective manner. Our residency in surgery participates in the annual Residents’ Survey required by the ACGME. Among the questions in the survey are two questions: first, ‘‘Does your program provide an environment where residents can raise problems or concerns without fear of intimidation or retaliation?’’ and second, ‘‘How satisfied are you with your program’s process to deal confidentially with problems and concerns residents might have?’’ In the 2010 survey, the results were clearly unacceptable, the noncompliant responses (‘‘no’’ in 2010; ‘‘somewhat,’’ ‘‘a little,’’ and ‘‘not at all’’ in 2011 and 2012) for intimidation–retaliation question at 58 per cent and the confidentiality question at 42 per cent. In response, we formed a Resident Advocacy Committee led by the administrative chief resident and Presented at the Association of Program Directors in Surgery annual meeting, San Diego, California March 21, 2012. Address correspondence and reprint requests to Don K. Nakayama, M.D., M.B.A., Department of Surgery, 1 Medical Center Drive, P.O. Box 9238, Health Sciences Center South, Suite 7700, Morgantown, WV 26506-9238. E-mail: [email protected].

trusted faculty who were not part of the administrative structure of the department of surgery. Their task was twofold: first, to conduct meetings of all residents whereby concerns were discussed with issues presented to the chair and faculty by the faculty representatives of the residents to assure anonymity. Second, the faculty representatives would be available for confidential meetings with individual residents. In its first year the Committee met four times and eight major issues were aired. In addition, private meetings occurred between three residents and one faculty member. Four major issues were adherence of due process of resident disciplinary actions, communication problems with the chair, inadequate supervision of critically ill patients by specific faculty members, and interactions with emergency department physicians. Other issues of concern in the department that affected residents were office staff firings, conflicts with the departmental secretary, location of the intern welcome party, and locations of resident cubicles. The creation of the Committee itself addressed the first two major issues, due process and communication problems with the chair. The Designated Institutional Official and the chair empowered the Committee to decide alternate solutions, providing an officially recognized alternative to stepwise chain of command. Faculty members on the Committee and the chief residents then reported back to the residents, closing the communication loop. The faculty gave residents additional standing in discussions on the other two important professional issues, supervision of care by attending surgeons and interactions with emergency department physicians, the senior surgeons giving the residents’ concerns additional heft. Issues regarding office staff firings were clarified through the Committee as were problems in communication with the departmental secretary. Residents’ opinions directly led to changes in the intern welcome party and assignments of cubicle space. Responses to the ACGME resident survey question, ‘‘Does your program provide an environment where residents can raise problems or concerns without fear

307

308

THE AMERICAN SURGEON

of intimidation or retaliation,’’ noncompliant responses decreased to 11 per cent in 2011 from 42 per cent in 2010; the 2012 rate remained essentially unchanged at 12 per cent. On the question, ‘‘How satisfied are you with your program’s process to deal confidentially with problems and concerns residents might have,’’ noncompliant responses decreased to 11 per cent in 2011 from 58 per cent in 2010 and increased to 17 per cent in the 2012 survey. In 2011, 84 per cent of residents responded that the overall training experience was either good (21%) or great (63%), a question not asked on the 2010 survey. This is the first report in the surgical literature to specifically address resident concerns and grievances, interventions to make improvements, and provide objective data that demonstrate improvement. Our experience reflects an overall problem residents have in addressing problems they encounter during training. Yeo and colleagues reported in a survey of U.S. surgical residents that only 66 per cent of female surgical residents and 75 per cent of male residents feel that they can turn to faculty for help during difficult times in their training.2 Although the national survey did not specifically address negative feedback and confidentiality, the levels of response reflected difficulty in accessing needed assistance when difficulties arise, presumably not only involving direct patient care, but workplace problems with other workers, environment, organizational issues, and hierarchy. Feedback, especially negative feedback, is essential to organizational improvement, yet, as Gallo3 notes, most people have compelling reasons to withhold their opinions from senior management, who control resources, determine promotions, and decide whether someone remains with the organization or is fired. Among her solutions to prevent directors from becoming insulated from hearing feedback was to assure anonymity and to rely on trusted associates who can communicate truthfully. She quotes Michael Green that ‘‘you need to develop relationships with people so they know they can tell you the truth without getting anyone in trouble.’’ Feedback from the Residents’ Survey revealed the erosion in communication and trust that had occurred in the residency. Alone the survey results reflected problems among the residents, but details came only after the Residents’ Advocacy Committee began to hear residents’ concerns. Hill and Lineback4 note that often a manager is unaware of his or her trustworthiness, the confidence that someone can be counted on to do the right thing. To make it clear that one is deserving of trust, they say, the manager may be required to act openly so that all can observe his or her reliability to make correct decisions. This transparency runs counter to some surgeons’ attitude that they make decisions independently without having to make explanations to

March 2014

Vol. 80

everyone involved. However, transparency allows all to see that decisions are made for the good of the organization, are not devious, and are free from selfish ambitions. Hill and Lineback conclude that trust develops when people can observe processes of decision-making and the actions that follow. Bryan C. Weidner, M.D. Brad M. Dennis, M.D. Macram M. Ayoub, M.D. Marcia B. Hutchinson, M.D. Department of Medical Education–Surgery Medical Center of Central Georgia Department of Surgery Mercer University School of Medicine Macon, Georgia Don K. Nakayama, M.D., M.B.A. Department of Surgery West Virginia University School of Medicine Morgantown, West Virginia REFERENCES

1. Accreditation Council for Graduate Medical Education. Resident services. Available at: www.acgme.org/acWebsite/resInfo/ri_ welcome.asp. Accessed September 29, 2012. 2. Yeo H, Viola K, Berg D, et al. Attitudes, training experiences, and professional expectations of U.S. general surgery residents, a national survey. JAMA 2009;302:1301–8. 3. Gallo A. How to get feedback when you’re the boss. Harvard Business School. HBR Blog network/best practices. May 15, 2012. Available at: http://blogs.hbr.org/hmu/2012/05/how-to-get-feedbackwhen-youre.html. Accessed October 6, 2012. 4. Hill L, Lineback K. Do your people trust you? Harvard Business School. HBR Blog network/best practices. March 2, 2012. Available at: http://blogs.hbr.org/hill-lineback/2012/03/do-yourpeople-trust-you.html. Accessed October 6, 2012.

Is Surgery Always Necessary in Patients with Abdominal Pain and Computed Tomographysuggested Intussusception? Adult small bowel intussusception (SBI) is rare entity and represents less than 0.1 per cent of all hospital admissions.1 As a result of its low incidence, there is a paucity of scientific evidence on the diagnosis and treatment of intussusception in adults. Prior studies2 suggest that all adults presenting with obstructive symptoms suspected to have SBI should undergo surgical exploration Presented at the Southeastern Surgical Conference, February 2012, Birmingham, Alabama. Address correspondence and reprint requests to Alan D. Chap, M.D., Staff Surgeon, Person Memorial Hospital, 515 Ridge Road, Roxboro, NC 27573. E-mail: [email protected].

No. 3

BRIEF REPORTS

for diagnostic and therapeutic purposes. This suggestion is based on the concern that the intussusception causing bowel obstruction may lead to intestinal ischemia as well as missing a malignant lead point.3 Computed tomography (CT) imaging has become routine for evaluation of acute abdominal pain and can image intussusception. CT can also suggest signs of ischemia as well as severity of obstruction based on bowel wall thickness, edema, and mesenteric abnormalities. However, does imaging of SBI correlate to clinical significance? We questioned the validity of surgical resection for all CT-suggested SBI. The primary objective was to evaluate the outcomes of the traditional surgical treatment and the nonoperative treatment for symptomatic CT-suggested SBI. The secondary objective was to determine which CT findings may be predictors of need for surgery. A retrospective cohort study was performed over an 18-month period at a university-affiliated hospital from 2010 to 2011. Ten patients who presented with acute abdominal pain and a CT-suggested SBI were identified. Each patient’s history and physical examination was reviewed. In patients who underwent surgery (the operative group), the postoperative diagnosis as well as the pathology was reviewed. Baseline demographics of age and gender were recorded. CT scan findings were analyzed specifically to note signs of obstruction, lead point, and the width of the intussusception. This study was approved by the Eastern Virginia School of Medicine’s Institutional Review Board (# 11-06-WC-0157). There were five females and six males with a median age of 49 years (range, 18 to 64 years). There were six patients in the operative group and four patients in the nonoperative group. Of the six patients who underwent surgery, three had negative explorations without any evidence of intussusception or other intra-abdominal pathology. The other three patients had the following pathologic findings: one large (5 cm) tubular adenoma (without evidence of dysplasia or invasive cancer), one jejunal intussusception (surgical history of laparoscopic gastric bypass) without a palpable lead point that was reduced, and one tubulovillous adenoma with foci of high-grade dysplasia. The predictors of the need for surgery were average bowel wall width (29.5 mm in the group with identifiable intraabdominal pathology vs 10.2 mm in the group with negative exploration) and the presence of a radiologically identified lead point and evidence for obstruction (present in the group with identifiable pathology). Of the patients with the negative explorations, two of the three returned to the emergency department with abdominal pain. One had a follow-up CT scan, which showed diverticulosis but no intussusception or other evidence for obstruction and was discharged home.

309

The other had a CT scan that was consistent with a small bowel obstruction and was admitted for nonoperative management. During his hospitalization, he underwent an upper gastrointestinal series with small bowel follow-through that did not show an obstruction or lead point and he was discharged home after being able to tolerate a regular diet. The three patients with intra-abdominal pathology on their initial operation were available for follow-up at a median of 2 months (range, 1 to 4 months). The patient with the large tubular adenoma had a normal colonoscopy. The patient with the tubulovillous adenoma with high-grade dysplasia had a hyperplastic rectal polyp on colonoscopy. The patient who underwent reduction of her jejunal intussusception was readmitted before her follow-up with abdominal pain. She did not have a recurrence of her intussusception, but rather had an obstruction that was causing dilation of her remnant stomach. Interventional radiology placed a percutaneous gastrostomy tube for decompression. She has had an upper gastrointestinal series and small bowel follow-through, which was normal in the interim and her remnant stomach was decompressed so she was able to have this gastrostomy tube removed. Two of the three patients in the nonoperative group were available for follow-up. One patient did undergo a colonoscopy, which demonstrated two tubular adenomas. The other had a history of bariatric surgery (performed out of state) and was seen by a new bariatric surgeon. She did not have any episodes of abdominal pain and has not undergone additional imaging. Combining the outcomes of both operative and nonoperative groups showed that only three of 10 (30%) patients needed surgical exploration. As evidenced by our study, the etiology of small bowel intussusception varies. A palpable lead point was present in only two patients. The proposed etiology in these cases is that this lead point telescopes into a distal segment of bowel during peristalsis and becomes entrapped.1 The etiology of SBI without a lead point is less clear. Olasky4 described patients with an active intraabdominal in a location remote from the intussusception. The authors suggest that during a state of peritoneal inflammation, the uninvolved bowel may be exposed to inflammatory mediators and bacteria through translocation leading to edema and this edematous bowel will ultimately be the lead point. Our patient without a palpable lead point did not have an inflammatory process, but she did have a history of gastric bypass and the intussusception was approximately 20 cm from the jejunal–jejunal anastomosis, perhaps acting as a physiologic lead point. Furthermore, small bowel dysmotility has been implicated as an etiology5 and

310

THE AMERICAN SURGEON

perhaps abnormal peristalsis was caused by electrolyte imbalances from decreased absorption of nutrients after the bypass. Our results show that nonoperative approach to CTsuggested SBI may be safe in symptomatic patients. Our study is limited by the small number of patients, which is understandable given that adult SBI is an uncommon etiology for abdominal pain. When considering nonoperative management, a through assessment needs to be performed in addition to the CT scan. With the nonoperative management strategy, patients should undergo follow-up imaging to rule out a malignancy or other pathology. The use of follow-up imaging modalities needs further evaluation but our study shows that upper gastrointestinal contrast study with a small bowel follow through is a reasonable option. CT scans have become routine as part of the evaluation of most adult patients presenting with abdominal pain and obstructive symptoms. All symptomatic CTsuggested SBI do not require operative management. A significantly thickened bowel with dilated proximal bowel suggestive of lead point and obstruction are more concerning and should be considered as more significant indicators for surgery, however, only as an adjunct to a good history and physical examination. Selective nonoperative management will hopefully save patients from the morbidity of a nontherapeutic laparotomy. These patients do need follow-up imaging to rule out intraluminal pathology. Alan D. Chap, M.D. Jimmie Nelson Collins, M.D. Department of Surgery Eastern Virginia Medical School Norfolk, Virginia L. D. Britt, M.D., M.P.H., S.C.C.M. Department of Surgery, General Surgery Residency Program, and Surgical Assistant Program Eastern Virginia Medical School Norfolk, Virginia REFERENCES

1. Azar T, Berger DL. Adult intussusception. Ann Surg 1997; 226:134–8. 2. Wang LT, Wu CC, Yu JC, et al. Clinical entity and treatment strategies for adult intussusceptions: 20 years’ experience. Dis Colon Rectum 2007;50:1941–9. 3. Goh BK, Quah HM, Chow PK, et al. Predictive factors of malignancy in adults with intussusception. World J Surg 2006;30: 1300–4. 4. Olasky J, Moazzez A, Barrera K, et al. In the era of routine use of CT scan for acute abdominal pain, should all adults with

March 2014

Vol. 80

small bowel intussusception undergo surgery? Am Surg 2009;75: 958–61. 5. Stubenbord WT, Thorbjarnarson B. Intussusception in adults. Ann Surg 1970;172:306–10.

Prospective Evaluation of Posttraumatic Vasospasm: Determining Its Clinical Significance after Traumatic Brain Injury Secondary injury processes play a critical role in the development of ischemia after trauma to the central nervous system and occur hours to days after the primary insult.1 Ischemia can lead to cerebral infarction or stroke. Ischemia has been described as the single most important secondary insult2 and has been identified histologically in approximately 90 per cent of patients who die after closed head injury.3 Several factors resulting in posttraumatic cerebral ischemia have been identified: increased intracranial pressure (ICP), systemic hypotension, and cerebral vasospasm. Cerebral vasospasm has been described as a sustained arterial narrowing unresponsive to vasodilator drugs and is classified as either angiographic or clinical. Angiographic vasospasm refers to the visible narrowing of the dye column on cerebral angiogram. Clinical vasospasm is the functional manifestation of cerebral ischemia produced by this arterial narrowing (vasoconstriction).4 Clinically, the onset of new or worsening neurological symptoms is the most reliable indicator of cerebral vasospasm after a ruptured cerebral aneurysm.4 However, cerebral vasospasm is often unrecognized in patients with moderate to severe traumatic brain injury (TBI). These patients frequently are altered as a result of the primary brain injury and additionally require narcotics for their pain and paralytics and/or sedatives while on mechanical ventilation. Thus, relying on the neurological examination to observe deteriorating neurological signs consistent with posttraumatic vasospasm (PTV) is unfeasible. Although the etiology and outcome of patients with vasospasm secondary to ruptured aneurysm are well documented, the clinical significance of PTV is unknown. The objective of this study was to evaluate the incidence and clinical significance of cerebral vasospasm in patients with moderate to severe TBI. A prospective, observational study was conducted in patients with moderate to severe blunt TBI (Glasgow Coma Score [GCS] 12 or less) with hemorrhage noted on a noncontrast head computed tomography (CT) scan, who required intensive care unit (ICU) admission at a Level I trauma center between February 2010 and Address correspondence and reprint requests to Ali Salim, M.D., Brigham and Women’s Hospital, Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, 75 Francis Street, Boston, MA 02115. Email: [email protected].

No. 3

BRIEF REPORTS

February 2011. Patients who were dead on arrival, dead within 24 hours, pregnant, had a history of cerebral aneurysm, had contraindications to CT and/or magnetic resonance imaging (MRI) scans, or allergies to iodinated contrast and/or gadolinium were excluded. All patients were admitted to the trauma/neurosurgical ICU and were jointly managed by the trauma team and a dedicated neurointensivist team. The management for patients followed established TBI guidelines. In addition, transcranial Doppler (TCD) ultrasound was conducted daily on all patients to detect PTV. If PTV was detected by TCD, CT brain angiography was then performed to confirm radiographic vasospasm by demonstrating arterial narrowing, which is an indirect

FIG. 1.

Study protocol.

311

measure of decreased tissue perfusion (i.e., ischemia). If vasospasm was confirmed by CT brain angiography, diffusion-weighted MRI or noncontrast head CT scan was used to confirm the presence of infarction (Fig. 1). Treatment for PTV occurred at the discretion of the neurointensivist and involved vasopressor use for blood pressure augmentation. Patient characteristics including age, gender, admission GCS, admission systolic blood pressure, admission temperature, ICP (measured just before TCD measurement), cerebral perfusion pressure (CPP), vasopressor use, Acute Physiology and Chronic Health Evaluation II scores, head Abbreviated Injury Score (AIS), and craniotomy/craniectomy and outcomes including mortality, ICU/hospital length of stay (LOS), and cerebral infarcts were compared between patients with and without PTV. Categorical variables were compared by the x2 or Fisher’s exact test. Numerical variables were compared by the t test or the Wilcoxon rank sum test. A P value < 0.05 was considered statistically significant. Descriptive statistics were summarized using frequencies, percentages, means, standard deviations, medians, and ranges. Statistical analysis was performed using SPSS for Windows Version 12.0 (SPSS, Inc., Chicago, IL) and SAS Version 9.1 (SAS Institute, Cary, NC). This study received Institutional Review Board approval by the Institutional Review Board of the Cedars-Sinai Medical Center. Twenty-nine patients met our inclusion criteria (Table 1). Most patients were men (82.8%) and had a mean GCS of 6.6 ± 3.1. The mean ICP was 9.1 ± 4.9 mmHg and mean CPP was 83.8 ± 15.0 mmHg. Fifty-five per cent underwent a craniotomy/craniectomy after admission. PTV was detected in 14 (48%) patients and occurred 3.9 ± 2.9 days postinjury. Of the patients with vasospasm, four (28.5%) patients had head AIS 5,

TABLE 1. Characteristics of the Patient Population Total Population (n 4 29) Vasospasm (n 4 14) No Vasospasm (n 4 15) P Value Age (years) Male Admission GCS Head AIS 3 4 5 Admission SBP (mmHg) Admission temperature (°F) (n 4 27) ICP (mmHg) (n 4 18) CPP (n 4 19) MAP (n 4 23) APACHE II (n 4 28) Craniotomy (n 4 16, yes)

42.4 ± 22.8 82.8% 6.5 ± 2.6

42.1 ± 21.5 78.6% 6.2 ± 2.0

42.8 ± 24.7 86.7% 6.7 ± 3.1

0.97 0.65 0.64

10.3% 51.7% 35.7% 156.0 ± 32.2 98.1 ± 2.0 9.1 ± 4.9 83.8 ± 15.0 90.3 ± 14.8 22.8 ± 7.3 55.2%

7.1% 57.1% 35.7% 162.6 ± 33.9 98.7 ± 2.0 9.3 ± 5.7 90.5 ± 15.8 94.4 ± 16.0 22.5 ± 6.2 71.4%

13.3% 46.7% 40.0% 149.7 ± 30.4 97.6 ± 1.8 8.8 ± 4.4 76.3 ± 10.3 85.8 ± 12.4 23.0 ± 8.4 40%

>0.99 0.29 0.16 0.82 0.08 0.17 0.87 0.14

GCS, Glasgow Coma Score; AIS, Abbreviated Injury Score; SBP, systolic blood pressure; ICP, intracranial pressure; CPP, cerebral perfusion pressure; MAP, mean arterial pressure; APACHE, Acute Physiology and Chronic Health Evaluation.

312

THE AMERICAN SURGEON

eight (57.2%) patients had head AIS 4, and one patient had head AIS 3. Cerebral infarcts were detected in four patients with PTV (29%) compared with three patients without PTV (20%) who developed infarcts (P 4 0.68). When comparing patients with and without vasospasm, there was no significant difference in patient characteristics (Table 1). Only one patient with severe vasospasm was treated with vasopressors for blood pressure augmentation. Subsequent evaluation demonstrated no evidence of infarction. This patient survived and was discharged from the hospital and to a rehabilitation facility. The overall mortality was 31 per cent. There were no significant differences in patient outcomes (mortality, ICP levels and management, ICU LOS, or hospital LOS) between patients with TBI with and without PTV. The current prospective observational study sought to evaluate the incidence and clinical significance of cerebral vasospasm in patients with moderate to severe TBI. PTV occurs in nearly 50 per cent of patients with moderate to severe TBI. Although 29 per cent of patients with TBI with PTV developed ischemic infarcts during their hospital course, there was no statistical difference compared with those without PTV. Further studies examining the role of PTV treatment and extended functional outcome are warranted to determine if PTV is at all clinically significant. Cherisse Berry, M.D. Eric J. Ley, M.D. Daniel R. Margulies, M.D. Jessica Pruett, B.A. Department of Surgery Division of Trauma and Critical Care Cedars-Sinai Medical Center Los Angeles, California Chad Miller, M.D. Department of Neurology Division of Cerebrovascular Diseases and Neurocritical Care Wexner Medical Center Columbus, Ohio Marko Bukur, M.D. Department of Trauma and Critical Care Broward Health and Del Ray Medical Centers Fort Lauderdale, Florida David Palestrant, M.D. Department of Neurology Division of Neurocritical Care Cedars-Sinai Medical Center Los Angeles, California

March 2014

Vol. 80

Darren Malinoski, M.D. Surgical Critical Care Section Portland Veterans Affairs Medical Center Portland, Oregon Ali Salim, M.D. Department of Surgery Division of Trauma, Burns, and Surgical Critical Care Brigham and Women’s Hospital Boston, Massachusetts REFERENCES

1. Emerson CS, Headrick JP, Vink R. Estrogen improves biochemical and neurological outcome following traumatic brain injury. Brain Res 1993;608:95–100. 2. Martin NA, Patwardhan RV, Alexander MJ, et al. Characterization of cerebral hemodynamic phases following severe head trauma: hypoperfusion, hyperemia, and vasospasm. J Neurosurg 1997;87:9–19. 3. Graham DI, Adams JH, Doyle D. Ischaemic brain damage in fatal non-missile head injuries. J Neurol Sci 1978;39: 213–34. 4. Falyar CR. Using transcranial Doppler sonography to augment the neurological examination after aneurysmal subarachnoid hemorrhage. J Neurosci Nurs 1999;31: 285–93.

Retrograde Flow Upper Extremity Fillet Flap for Coverage of a Large Thoracic Wall Defect Pedicled and free fillet flaps have been successfully used for the coverage of defects after traumatic amputations or oncologic resections.1–3 In our review of the literature, no previous description of using fillet flaps with retrograde flow was found. We present successful coverage of a large thoracic wall defect with a retrograde upper limb fillet flap. The main blood supply of the flap was based on retrograde blood flow from the radial artery. We present a case of 64-year-old woman with a history of phyllodes tumor of the left breast operated several times over the last eight years resulting from multiple local recurrences (Fig. 1). The last operation was performed five months prior. The tumor had been conservatively resected along with the left subclavian artery as a result of its involvement with the tumor. The defect had been covered with a trapezius flap and vein graft had been used to reconstruct the continuity of the subclavian artery. However, the patient a few months Address correspondence and reprint requests to Stamatis Sapountzis, M.D., or Hung-Chi Chen, M.D., Ph.D., Department of Plastic Surgery, China Medical University Hospital/China Medical University, 2, Yuh-der Road, Taichung, Taiwan. E-mail: [email protected] or [email protected].

No. 3

BRIEF REPORTS

313

FIG. 1. (Left) Recurrent phyllodes tumor of the left breast, extended to the axilla and the left upper limb. (Right) Seven months postoperatively.

FIG. 2. Extensive resection of the tumor along with the subclavian and the axillary artery, the scapula, and three ribs. Mesh was used to reconstruct the chest wall defect. A fillet flap was harvested and the radial vessels were dissected distally at the level of the wrist to be used for revascularization of the flap.

later presented to our department with a recurrent extensive tumor over the left thoracic wall, which extended to the axilla and the left arm. On physical examination the left upper limb had limited function as a result of involvement of the brachial plexus by the tumor. The preoperative plan was extensive resection of the tumor and coverage of the thoracic wall defect with a pedicled fillet flap from the left upper extremity. However, during the operation, the vein graft of the subclavian artery was found to be thrombosed and surrounded by the tumor; the scapula was also involved by the tumor and resected as well as three ribs, which were also resected. A large thoracic wall defect was created approximately 30 · 50 cm in size, which was unable to be covered by the soft tissue of the upper limb as a pedicled fillet flap as a result of extensive resection of the subclavian and the axillary artery. As a result of prolonged ischemia time

of the upper limb (8 hours), because the tumor resection was quite tedious, the muscles of the upper limb were sacrificed, and the radial artery and vein were dissected distally on the wrist to be used for revascularization of the upper extremity skin as a retrograde flow flap (Fig. 2). The contralateral thoracoacromial vessels were used as recipient vessels, and one arterial and two venous anastomoses were performed. The skin of the upper left limb successfully covered the defect, and its blood supply was based on a random vascular network proximally and the left radial artery distally, which was anastomosed with the right thoracoacromial artery. The postoperative period was uneventful and the flap survived well apart from a small area on the proximal inferior part of the flap, which healed spontaneously by secondary intention. At the 7-month follow-up, no sign of tumor recurrence was noted.

314

THE AMERICAN SURGEON

In conclusion, the presented case attempts to expand the use of the upper limb fillet flap revealing its reliability as a retrograde flow flap with a secondary random pattern pedicle in reconstruction of complex thoracic wall defects. Stamatis Sapountzis, M.D. Pedro Ciudad, M.D. Ram Chilgar, M.D. Fabio Nicoli, M.D. Dhruv Singhal, M.D. Hung-Chi Chen, M.D., Ph.D., F.A.C.S. Department of Plastic Surgery China Medical University Hospital Taichung, Taiwan REFERENCES

1. Mohammed F, Romany S, Ramdass MJ, et al. A pedicle forearm fillet flap aided by subperiosteal proximal dissection in shoulder disarticulation. Plast Reconstr Surg 2002;109: 2431–3. 2. Ghali S, Harris PA, Khan U, et al. Leg length preservation with pedicled fillet of foot flaps after traumatic amputations. Plast Reconstr Surg 2005;115:498–505. 3. Ver Halen JP, Yu P, Skoracki RJ, Chang DW. Reconstruction of massive oncologic defects using free fillet flaps. Plast Reconstr Surg 2010;125:913–22.

Treatment of Perforated Appendicitis in Children: Focus on Phlegmon The management of perforated appendicitis in children has been studied extensively but continues to be actively debated regarding the roles of nonoperative management versus immediate appendectomy for this condition.1, 2 Comparisons between studies have always been hampered by variations in the definition of perforated appendicitis and its spectrum of clinical presentation, including the presence of a phlegmon and/or abscess, which many have classified together as ‘‘complicated’’ appendicitis. We know of no studies to date that have examined the complicated appendiceal phlegmon independently from abscess, although definitions have been proposed.3 Our study presents a singleinstitution retrospective review of initial nonoperative management versus immediate appendectomy for a large cohort of pediatric patients treated for perforated appendiceal phlegmon. We retrospectively identified all patients (n 4 106) who were diagnosed with perforated appendiceal Address correspondence and reprint requests to Catherine Chen, M.D., M.P.H., Department of Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115. E-mail: [email protected].

March 2014

Vol. 80

phlegmon and treated at Boston Children’s Hospital from 2007 through 2009. Patients with a phlegmon had an inflammatory mass with or without nondrainable defined fluid collection(s) that were less than 3 cm in diameter based on review of radiologic and/or operative findings at presentation. We excluded patients with a free perforation (free fluid with no defined collections) or those with an abscess (well-defined, fluid collection[s] greater than or equal to 3 cm in diameter). Clinical data were collected for all hospital encounters from initial presentation through the final outpatient visit as per our Institutional Review Board-approved study (M08-09-0435). Patients were treated based on attending pediatric surgeon (n 4 17) preference with either immediate surgery or initial nonoperative management with or without interval appendectomy six to eight weeks later after an initial course of intravenous (IV) antibiotics. At our institution during the study period, the clinical pathway for treatment of perforated appendicitis included placement of a peripherally inserted central catheter (PICC) line and treatment with at least ten days of IV antibiotics followed by oral antibiotics if needed. Surgical site infections (SSIs) were tabulated based on previously accepted definitions.4 All patients undergoing appendectomy were confirmed to have perforated appendicitis by review of surgical pathology. During the study period, 99 patients had a free perforation; all but one of whom was treated with immediate surgery, whereas 83 patients presented with an abscess with 74 patients undergoing initial nonoperative management (data not shown). We present data on only the patients with phlegmon. The mean age was 9.7 years (standard deviation [SD] 4.4) with 54 per cent males and mean body mass index of 18.8 kg/m2 (SD 3.6). The majority of patients were white (69%) with 7 per cent black and 9 per cent Hispanic/Latino. Seventy-two per cent had private insurance. Presenting symptoms included vomiting (72%), focal right lower quadrant pain (60%), diffuse abdominal tenderness (39%), nausea (26%), and diarrhea (22%). The mean duration of symptoms was 3.7 days (SD 6.0). On admission, the mean temperature was 37.6°C (SD 0.9) and mean white blood cell count was 15.6 (SD 4.9). At presentation, all 106 patients received abdominal imaging: ultrasound only (nine of 106 [8%]), computed tomography (CT) only (42 of 106 [40%]), and both studies (55 of 106 [52%]). Sixty per cent (n 4 64) of patients underwent initial nonoperative management with nine patients (14%) eventually requiring an interventional radiology (IR) drainage procedure preoperatively (Table 1), and one requiring two drainage procedures. After completion of the IV antibiotic course through a PICC line in the majority of cases (98%), 58 patients

No. 3

BRIEF REPORTS

underwent interval appendectomy (97% received preoperative antibiotics; 97% laparoscopic) with few postoperative complications (Table 2). Two patients received antibiotics during the operative case but after the incision was made. In contrast, Table 2 shows that those patients undergoing immediate surgery (n 4 42 [40%]; 95% laparoscopic) had a significantly increased incidence of postoperative complications. Four patients (10%) developed a postoperative organ/space SSI with three of these patients requiring a single postoperative IR drainage (Table 1), whereas no patients in the initial nonoperative management group developed this complication (P 4 0.03). Five patients (12%) developed an

315

ileus requiring total parenteral nutrition (TPN) compared with none in the initial nonoperative management group (P 4 0.01). There were no other statistically significant differences in major or minor complications between the two treatment groups (Table 2). Patients with a phlegmon who were treated with immediate surgery had fewer median hospital admissions (one vs two), a shorter total hospital length of stay (LOS; 6.5 vs 9 days), and a shorter total duration of antibiotics (12 vs 15 days) than patients treated with initial nonoperative management (P < 0.01, P 4 0.01, and P < 0.01, respectively). Nearly all patients received a PICC line regardless of treatment type with four PICC line complications noted in the initial

TABLE 1. Hospital Course Initial Nonoperative Management (n 4 64)

Immediate Surgery (n 4 42)

P

2 (1–4) 9 (3–24)

1 (1–3) 6.5 (3–30)