Enterocutaneous Fistulas

Enterocutaneous fistulas (ECF) represent a catastrophic problem for patients and continue to be complex and labor intensive for healthcare providers. In addition to the many physiologic and mental stressors the patients must endure, the development of ECFs also puts a strain on healthcare systems resulting in prolonged hospital stays, multiple readmissions, and increased resource consumption. The management of ECFs has improved significantly, resulting in decreased mortality rates, from 50% in the 1950s to approximately 5%–15% at present. As many as 85% of ECFs present as a complication after abdominal surgery, providing further challenges to already compromised postoperative patients. Most ECFs develop as a result of one of the following conditions: extension of bowel disease to surrounding structures, extension of disease of the surrounding structures to the bowel, unrecognized bowel injury, or breakdown of a gastrointestinal tract anastomosis. Multiple preoperative patient factors can increase the likelihood of ECF development

Computed tomographic angiography in pediatric blunt traumatic vascular injury

Pediatric vascular injuries are rare but can be difficult to diagnose and challenging to manage. We present our experience with computed tomographic angiography in 3 pediatric patients with vascular injuries secondary to blunt trauma. Computed tomographic angiography is noninvasive, fast, rapidly available in most centers, and can evaluate for other injuries. We present a review of the literature and recommend computed tomographic angiography as the diagnostic tool of choice in the evaluation of pediatric blunt vascular trauma

Value of computed tomographic angiography in neck and extremity pediatric vascular trauma

We sought to define the sensitivity and specificity of computed tomographic angiography (CTA) in pediatric vascular injuries. All neck and extremity CTAs performed in pediatric patients at a level 1 trauma center were reviewed from 2001 to 2007. Overall, 78 patients were identified with an average age of 15.0 ± 4.0 (0-18 years). Males outnumbered females 3.6:1. CTA was performed for 41 penetrating and 37 blunt traumas. Most penetrating injuries were due to missile wounds (71%) or stab wounds (17%). Eleven major vascular injuries resulted from penetrating trauma. For penetrating trauma, CTA was 100% sensitive and 93% specific. CTA for penetrating trauma had a positive predictive value (PPV) of 85% and negative predictive value (NPV) of 100%. Most blunt injuries were due to motor vehicle accidents (57%), followed by pedestrian hit by car (27%). Eight major vascular injuries resulted from blunt trauma. For blunt trauma, CTA was 88% sensitive and 100% specific. CTA for blunt trauma had a PPV of 100% and an NPV of 97%. The accuracy for penetrating and blunt trauma was 95% and 97%, respectively. CTA is highly sensitive, specific, and accurate for pediatric neck and extremity vascular trauma

Heparineless off-pump coronary artery bypass in a patient with gunshot wound to chest and heart

Administration of heparin is standard in coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (OPCABG). In some circumstances, the risk of heparinization may outweigh its benefits, and there is scarce literature on how to proceed in these cases. We describe the technique used for OPCABG without heparin. We report the case of a patient with a gunshot wound to the chest resulting in multiple lung lacerations and transection of the proximal left anterior descending coronary artery (LAD) leading to hemorrhagic shock with tamponade, and cardiogenic shock due to myocardial ischemia who received OPCABG without heparin. A 23-year-old patient suffered multiple gunshot wounds to the chest and was admitted in shock with massive left hemothorax. Emergency left thoracotomy revealed multiple lung lacerations and transection of the proximal left anterior coronary artery. The patient presented acute myocardial ischemia and progressed to cardiogenic shock requiring insertion of intra-aortic balloon pump (IABP) to try to support hemodynamics. OPCABG with a segment of reversed saphenous vein graft to the LAD coronary artery was performed using standard techniques but without heparinization. The graft was flushed with normal saline before completing both anastomosis. Myocardial ischemic changes reversed, and the patient stabilized immediately after completing OPCABG, allowing to wean off IABP in the operating room. Postoperative recovery was unremarkable, and the patient was discharged home on postoperative day 9. Benefits of OPCABG include decreased bleeding and lower requirement of blood transfusions. This experience shows that OPCABG can be performed without systemic heparinization in selected cases

Alcohol/Illicit Substance Use in Fatal Motorcycle Crashes

The objective of the current study is to determine how alcohol and illicit substance use contributes to motorcycle crash fatalities by examining the relationship between toxicology levels found postmortem and the behavior of riders and passengers in fatal motorcycle crashes. All motorcycle fatalities in Miami-Dade County, FL, from 2009 to 2014 were reviewed using the Miami-Dade County Medical Examiner's toxicology reports and the corresponding crash reports. Positive alcohol/illicit substance detection was found in 44% of our population of 227 fatalities. When compared with those with a negative alcohol/illicit substance detection, those with a positive alcohol/illicit substance detection were more likely to be found at fault of the crash (77% versus 50%, P < 0.001), more likely to be in a single-vehicle crash (47% versus 21%, P < 0.001) and less likely to wear a helmet (44% versus 64%, P = 0.002). However, there was no significant relationship between speeding and alcohol/illicit substance detection (29% versus 33%, P = 0.748). In addition, a regression analysis demonstrated that there was less helmet use and more single-vehicle crashes with higher blood alcohol concentration. In fatal motorcycle crashes, alcohol and illicit substance use had a significantly negative impact on the risk aversion of motorcycle fatalities in regard to fault, helmet use, and single-vehicle crashes