Laparoscopy reduces iatrogenic splenic injuries during colorectal surgery

Background

Splenic injury can occur during colorectal surgery especially in cases, where the splenic flexure is mobilized. The aim of this study was to analyze whether the operative approach (laparoscopic vs. open) was associated with an increased risk for splenic injury during colorectal surgery and to compare the outcomes of different management options.

Methods

All accidental injuries that occurred during colorectal resections performed in our department between January 2010 and June 2013 were identified from an administrative database. All patients with iatrogenic splenic injuries were classified into two groups according to the operative approach. Only procedures that required splenic flexure mobilization were included. Splenic injury management options and outcomes were compared.

Results

There were 2336 colorectal resections (1520 open, 816 laparoscopic) performed during the study period. There were 25 (1.1%) iatrogenic splenic injuries. 23 out of 25 splenic injuries occurred during open colorectal surgery. Overall, 16 (64%) patients were managed with topical hemostatic methods, 5 (20%) with splenectomy, and 4 (16%) with splenorrhaphy. It was possible to salvage the spleen in both laparoscopic patients. The laparoscopic approach was associated with a lower splenic injury rate (0.25% vs. 1.5%, p?=?0.005) and a lower need for splenectomy/splenorrhaphy (p?=?0.03).

Conclusions

Our data suggest that laparoscopic colorectal surgery may be associated with a lower risk of iatrogenic splenic injury, and that most splenic injuries can be managed with spleen-preserving approaches.

     

Medical malpractice and the chest physician

The US malpractice system is based on tort law, which holds physicians responsible for not harming patients intentionally or through negligence. Malpractice claims are brought against physicians from most medical disciplines in proportion to their numbers in practice and to the frequency with which they perform procedures. Claims against chest physicians most commonly allege injuries caused by the following: (1) errors in diagnosis, (2) improper performance of procedures, (3) failure to supervise or monitor care, (4) medication errors, and (5) failure to recognize the complications of treatment. Most of these injuries occur in hospitals, and many of the injured patients die. The social goals of the medical malpractice system include the following: (1) compensating patients injured through negligence, (2) exacting corrective justice, and (3) deterring unsafe practices by creating an economic incentive to take greater precautions. Some patients injured through negligence are compensated, but most are not. Claims are brought against some negligent physicians but also some who are not negligent, and being negligent does not guarantee that a claim will be brought. The deterrent effect of medical malpractice is unproven, and the malpractice system may prompt defensive medicine and increase health-care costs. And by stressing individual accountability, it conflicts with a systems-oriented approach to reducing medical errors.     

Liver transplantation in the treatment of severe iatrogenic liver injuries

The place of liver transplantation in the treatment of severe iatrogenic liver injuries has not yet been widely discussed in the literature. Bile duct injuries during cholecystectomy represent the leading cause of liver transplantation in this setting, while other indications after abdominal surgery are less common. Urgent liver transplantation for the treatment of severe iatrogenic liver injury may-represent a surgical challenge requiring technically difficult and time consuming procedures. A debate is ongoing on the need for centralization of complex surgery in tertiary referral centers. The early referral of patients with severe iatrogenic liver injuries to a tertiary center with experienced hepato-pancreatobiliary and transplant surgery has emerged as the best treatment of care. Despite widespread interest in the use of liver transplantation as a treatment option for severe iatrogenic injuries, reported experiences indicate few liver transplants are performed. This review analyzes the literature on liver transplantation after hepatic injury and discusses our own experience along with surgical advances and future prospects in this uncommon transplant setting.     

Prognosis and treatment of pancreaticoduodenal traumatic injuries: which factors are predictors of outcome?

Background/purpose

Abdominal trauma rarely causes injuries involving the duodenum and pancreas. Associated injuries occur in 46% of all pancreatic injuries. The morbidity and mortality of pancreaticoduodenal injuries remain high.

Methods

The present study is a retrospective review of our experience from 1989 to 2008 in the surgical treatment of traumatic pancreaticoduodenal injuries. Mortality, morbidity, prognostic factors, and the value of surgical techniques were analyzed.

Results

In our level I Trauma Center, between 1989 and 2008, 55 patients had a pancreaticoduodenal injury. In 68.5% of cases pancreatic injuries were found, 20.4% had duodenal injury, and 11.1% suffered combined pancreaticoduodenal injuries; 85.3% of the patients had blunt abdominal trauma, while 14.9% had penetrating injuries. We treated 78.1% of the patients with external drainage and/or simple suture; distal pancreatectomy was performed in 9% of cases and duodenal resection with anastomosis (3.7%) and diversion procedures (3.7%) were performed in an equal number of patients. Age, American Association for the Surgery of Trauma (AAST) grade, organ involved, hemodynamic status, intraoperative cardiac arrest, and operative time remained strongly predictive of mortality on multivariate analysis. The AAST grade represented, on multivariate analysis, the only independent prognostic factor predictive of overall morbidity. In the past decade we have used feeding jejunostomy more frequently, with a reduction of mortality and operating time, due also to a better approach from a dedicated trauma team.

Conclusions

Optimal management and better outcome of pancreaticoduodenal injuries seem to be associated with shorter operative time, and with simple and fast damage control surgery (DCS), in contrast to definitive surgical procedures.     

Arterial Embolization for Hemorrhage Caused by Hepatic Arterial Injury

Fewer than 10% of patients with major liver trauma have life-threatening bleeding. Laparoscopic operations, endoscopic procedures, and percutaneous interventions such as drainages, vascular or tumor sclerosis, biopsies, and transjugular intrahepatic portocaval shunt (TIPS) have increased the number of iatrogenic vascular and bile duct injuries. Due to its therapeutic success, arterial embolization (AE) has become the standard treatment for late complications of hepatic injury. In some cases, this procedure may be used as the first approach on accidental or iatrogenic arterial trauma and in several hepatic arterial diseases. The result of this method depends on physician experience, size of the wound, and stability of the patient. Persistent hemorrhage and rebleeding may be treated with a new AE or an operation. Precise indication and a correctly performed AE are key factors for a successful treatment. Rebleeding episodes are a rare occurrence, which may be treated with AE as well.     

A state‐of‐the‐art review of esophageal trauma: where do we stand?

The esophagus provides a diagnostic and therapeutic pathway not only for gastroenterologists but for surgeons, radiologists, cardiologists, and other specialists. Unfortunately, this procedural traffic occasionally leads to iatrogenic injury. As well, though reasonably well protected anatomically, frank esophageal injuries due to non-iatrogenic causes are not uncommon. We present a review of the literature on this subject covering anatomy, etiology, diagnostics, therapeutics, and management generally.     

Orthopaedic injuries following falls by hospital in-patients

BACKGROUND: Falls are one of the most frequent episodes on the hospital wards. Objective: To identify orthopaedic injuries sustained by in-patients falling on the hospital wards and to find out what treatment these required along with the additional time and cost that this incurred. METHODS: A retrospective analysis of 900 incident forms and case records was undertaken for a 3-year period. Fractures and other soft-tissue injuries sustained and time, place, and mode of injury were noted. Type of fractures sustained and specific treatment required including operative procedure needed were studied. The cost of each treatment and the total cost in terms of time and money were calculated. RESULTS: We identified 42 patients with orthopaedic injuries; 53% of the falls were recorded on medical wards. A poor pre-fall mobility was an important factor in over 80% of the cases, and a variety of medical conditions pre-existed in the elderly ill patients. Eighteen patients (42%) sustained hip fractures, of whom 15 patients (36%) required surgical treatment. There were 9 deaths in total, 5 of them occurred in patients with hip fractures. The cost of treating the injuries amounted to about GBP 70,000. An additional hospital stay of 56 weeks in total was needed, most patients requiring between 1 and 5 weeks of additional stay. CONCLUSIONS: Falls in elderly in-patients can result in a variety of skeletal injuries. These may require major operative procedures and result in significant morbidity and can prove fatal. The treatment of these injuries is a substantial added expenditure to the trust.     

Surgical management of colorectal injuries: colostomy or primary repair?

Purpose

Several factors have been considered important for the decision between diversion and primary repair in the surgical management of colorectal injuries. The aim of this study is to clarify whether patients with colorectal injuries need diversion or not.

Methods

From 2008 to 2010, ten patients with colorectal injuries were surgically treated by primary repair or by a staged repair.

Results

The patients were five men and five women, with median age 40 years (20–55). Two men and two women had rectal injuries, while 6 patients had colon injuries. The mechanism of trauma in two patients was firearm injuries, in two patients was a stab injury, in four patients was a motor vehicle accident, in one woman was iatrogenic injury during vaginal delivery, and one case was the transanal foreign body insertion. Primary repair was possible in six patients, while diversion was necessary in four patients.

Conclusions

Primary repair should be attempted in the initial surgical management of all penetrating colon and intraperitoneal rectal injuries. Diversion of colonic injuries should only be considered if the colon tissue itself is inappropriate for repair due to severe edema or ischemia. The role of diversion in the management of unrepaired extraperitoneal rectal injuries and in cases with anal sphincter injuries is mandatory.

     

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions

PURPOSE: To identify the frequency and type of iatrogenic medical events requiring admission to an intensive care unit. To assess the consequences of iatrogenic medical events for patients and institutions. To assess the prevalence of disclosure of iatrogenic medical events to patients, surrogates, and institutions. METHODS: The project on Care Improvement for the Critically Ill enrolled 5727 patients to 8 intensive care units at 4 Boston teaching hospitals. To determine the nature, consequences, and disclosure of iatrogenic medical events, we did a retrospective chart review on all patients whose admission to an intensive care unit was precipitated by an iatrogenic event. RESULTS: Sixty-six patients (1.2 %) were identified by an intensive care unit's clinical team as having an iatrogenic medical event as the primary reason for admission to the unit. The majority (29, or 45%) of iatrogenic medical events were secondary to technical error, but a high percentage (21, or 33%) was due to iatrogenic drug events. Twenty-two (34%) cases were assessed by the investigators to have been preventable. In 60 (94%) cases there was no documentation in the patient's chart of communication to the patient regarding the reason for admission to the intensive care unit. In 11 (17%) cases there was documentation of a discussion with the surrogate about the reason for admission to the unit. In only 3 (5%) cases was there documentation that the patient or surrogate was informed that an iatrogenic medical event was the reason for admission to the intensive care unit. Incident reports or malpractice claims were filed in only 4 (6 %) cases. CONCLUSION: The frequency of iatrogenic medical events resulting in admission to intensive care units is lower than previous studies have reported. Iatrogenic drug events continue to be an important source of error. A considerable percentage of iatrogenic events may be preventable. Health care professionals rarely document disclosure of iatrogenic events to patients and surrogates.     

Medical malpractice involving colon and rectal disease: A 20-year review of United States civil court litigation

To determine objectively the causes of malpractice litigation involving colon and rectal disease, a retrospective review was undertaken of all cases tried in the U.S. federal and state civil court system over a 21-year period from 1971 through 1991. Ninety-eight malpractice cases were identified from a computerized legal data base, involving 103 allegations of negligence. Allegations fell into five major categories: 1) failure to timely diagnose disease, principally colorectal cancer and appendicitis (n=44/ 103; 43 percent); 2) iatrogenic colon injury (n=25/ 103; 24 percent); 3) iatrogenic medical complications during diagnosis or treatment (n=16/103; 15 percent); 4) sphincter injury with fecal incontinence, resulting from anorectal surgery or midline episiotomy (n=10/ 103; 10 percent); and 5) lack of informed consent, especially regarding extent of procedures or risk of endoscopy (n=8/103; 8 percent). These data may aid in design of risk prevention strategies related to the diagnosis and treatment of colorectal disease.Supported in part by a grant from United States Surgical Corporation, Norwalk, Connecticut.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Fälle aus dem Grenzgebiet zwischen Geriatrie und Unfallchirurgie

Medical arbitration boards (“Schlichtungsstellen”, expert panels for extrajudicial malpractice claim resolution) try to settle claims of suspected malpractice between patients and their physicians and to avoid court trials. Numerous studies found an increasing incidence of adverse events with rising age. Injuries that occur in the hospital are frequently beyond the specialty of the treating physician. Therefore, the physician has to broaden his diagnostic view beyond the borders of his own specialty to recognize injuries in his patients and to prevent malpractice claims. In this paper, we report on adverse events in elderly patients where the geriatrician/internist was accused of negligence for not having promptly recognized a fracture after a fall or having chosen an inadequate operative procedure. For example, the importance of weight bearing osteosynthesis, mandatory in hip fractures in the elderly population to prevent long-term immobilization, is discussed. Adverse events due to negligence are more frequent among the elderly; the reasons are discussed. They will never be entirely preventable. The data presented in this report may be helpful to recognize fractures in time and to ensure adequate treatment, in order to reduce the number of court claims.     

Laparoscopic cholecystectomy: incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations

BackgroundEven though laparoscopic cholecystectomy (LC) has become the customary method for treating gallstones, some incidents and complications appear rather more frequently than with the open technique. Several aspects of these complications and their treatment possibilities are analysed.Materials and methodsOver the last 9 years 9542 LCs have been performed at this centre, of which 13.9% were carried out for acute cholecystitis, 38.4% in obese patients and 7.6% in patients aged >65 years.ResultsThe main operative incidents encountered were haemorrhage (224 cases, 2.3%), iatrogenic perforation of the gallbladder (1517 cases, 15.9%) and common bile duct (CBD) injuries (17 cases, 0.1%). Conversion to open operation was necessary in 184 patients (1.9%), usually due to obscure anatomy as a result of acute inflammation. The main postoperative complications were bile leakage (54 cases), haemorrhage (15 cases), sub-hepatic abscess (10 cases) and retained bile duct stones (11 cases). Ten deaths were recorded (0.1%).DiscussionMost of the postoperative incidents (except bile duct injuries) were solved by laparoscopic means. Among patients with postoperative complications 28.9% required revisional surgery. In 42.2% of cases minimally invasive procedures were used successfully: 15 laparoscopic re-operations (for choleperitoneum, haemoperitoneum and subhepatic abscess) and 22 endoscopic sphincterotomies (for bile leakage from the subhepatic drain and for retained CBD stones soon after operation). The good results obtained allow us to recommend these minimally invasive procedures in appropriate patients.     

Iatrogenic bile duct injuries from biliary tract surgery

BACKGROUND:Cholecystectomy is the most commonly performed procedure in general surgery.However,bile duct injury is a rare but still one of the most common complications.These injuries sometimes present variably after primary surgery.Timely detection and appropriate management decrease the morbidity and mortality of the operation. METHODS:Five cases of iatrogenic bile duct injury(IBDI) were managed at the Department of Surgery,First Affiliated Hospital,Xi'an Jiaotong University.All the cases who underwent both open and laparoscopic cholecystectomy had persistent injury to the biliary tract and were treated accordingly. RESULTS:Recovery of the patients was uneventful.All patients were followed-up at the surgical outpatient department for six months to three years.So far the patients have shown good recovery. CONCLUSIONS:In cases of IBDI it is necessary to perform the operation under the supervision of an experienced surgeon who is specialized in the repair of bile duct injuries,and it is also necessary to detect and treat the injury as soon as possible to obtain a satisfactory outcome.     

Pill esophagitis.

Nine hundred seventy-nine cases of pill esophagitis due to nearly 100 different medications are reviewed. Pill-induced injuries occur when caustic medicinal pills dissolve in the esophagus rather than passing rapidly into the stomach as intended. Most patients suffer only self-limited pain, but esophageal hemorrhage, stricture, and perforation may occur, and fatal injuries have been reported. The incidence of this iatrogenic injury can be reduced but not eliminated by emphasizing the importance of taking pills while upright and with plenty of fluids.     

Surgical treatment of hepatic injury: morbidity and mortality analysis of 109 cases

BACKGROUND/AIMS: We aimed to determine the factors that affect morbidity and mortality in patients that underwent surgery for hepatic injury. METHODOLOGY: Records of 109 blunt or penetrating hepatic trauma patients that underwent surgery in the Third Surgical Clinic of Izmir Atattürk Training and Research Hospital between 1994 and 2004 were reviewed retrospectively. Evaluated parameters were: age, gender, cause of injury, diagnostic procedures, preoperative blood pressure (BP), hemoglobin (Hb) level, amount of intraabdominal blood, associated injuries, the number of involved hepatic segments and anatomic distribution, severity of injury, abdominal trauma index (ATI), amount of blood transfusions, type of surgery, hospital stay, and rates of morbidity and mortality. RESULTS: Median age of the patients was 29 years. The injury was penetrating in 53.2% of the patients and blunt in 46.8%. Abdominal blood was 500cc or less in 70 (64.2%) patients. Isolated hepatic injury was encountered in 29 (26.6%) cases. 22.9% of the patients had major injuries. Hemostasis was achieved by electrocautery, sponge-gel, primary suturing, hepatic resection or perihepatic packing. Morbidity and mortality rates were 40.4% and 14.6% respectively. CONCLUSIONS: Age, type of the injury, BP and Hb levels, amount of intraabdominal blood, degree of injury, ATI, and accompanying organ injuries significantly affect morbidity and/or mortality.     

Surdosages en antivitamines K : audit de la prise en charge hospitalière

Introduction

Vitamin K antagonists (VKA) are drugs with a major risk of side effect. Guidelines have been published in 2008 by the Haute Autorité de santé (HAS) concerning the management of an excessively elevated INR ratio. Our research aimed to assess physicians’ adherence to those guidelines.

腹部外伤早期再手术18例分析

目的探讨腹部外伤早期再手术的原因和预防：方法对近10年18例腹部外伤早期再手术病人进行分析。结果18例病人共行再手术20例次，其中2例经受2次再手术。死亡2例，病死率为11.1％。再手术原因主要为首次手术漏诊(6例)、处置失误(6例)、并发症(5例)、阴性再手术(1例)。结论全面探查、术式合理、腹腔彻底冲洗和充分引流，是减少腹部创伤再手术的关键，     

The cost of medical care for injuries to children

STUDY OBJECTIVES: To estimate the mean cost of initial medical treatment for a variety of injury types and injury causes and project the national cost of initial medical care for injuries to children. DESIGN: We combined injury incidence data from the Massachusetts Statewide Childhood Injury Prevention Project (SCIPP) with a claims data set (1987 charges) from the Health Data Institute, Lexington, Massachusetts. SETTING AND STUDY POPULATION: SCIPP incidence data were obtained from hospital emergency department and inpatient facilities for a population of 87,000 Massachusetts children 0 to 19 years old between 1979 and 1982. Health Data Institute charge data for children were derived from insurance claims for 3% of all privately insured patients throughout the United States. RESULTS: The estimated mean cost of initial hospitalization for injury was $5,094, while ED care was $171. Projected annual cost for initial medical care of injury to children for the nation was $5.1 billion, which was about equally divided between cases seen in EDs and those requiring inpatient care. Although there was little difference in mean cost between the genders, mean cost increased with age. Because of both a higher injury incidence and a greater mean cost per injury, the projected initial cost of injuries to teenagers 15 to 19 years old was much higher than that of younger children. CONCLUSION: Expenditures for medical care of injured children, particularly adolescents, are great. The prevention of childhood injuries should become a higher priority in the United States. To improve the quality of national estimates of the incidence and cost of injury, a national surveillance system for nonfatal injuries should be developed. Such a system should include information on the major causes of injury and their costs.     

Enterovesical fistulas: diagnosis and management

Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. It represents a rare complication of inflammatory or neoplastic disease, and traumatic or iatrogenic injuries. The most common aetiologies are diverticular disease and colorectal carcinoma. Over 75% of affected patients describe pathognomonic features of pneumaturia, faecaluria and recurrent urinary tract infections. The diagnosis of EVF can be challenging, and frequently patients are monitored for months before the condition is recognised and treated effectively. Diagnostic tools include laboratory tests, imaging studies and endoscopic procedures. Although conservative management can be attempted in selected patients, in most cases, the treatment is mainly based on surgical interventions. Recently, the laparoscopic approach to EVF has been shown to be safe and effective. Although it is a rare condition in a general surgery setting, EVF is a challenging condition leading to high morbidity and mortality rates.     

Aetioepidemiological profile of spinal injury patients in Eastern Nepal

This is a retrospective case series of 233 spinal injury patients admitted to the orthopaedic ward of BPKIHS from May 1997 to April 2001. The inpatient records were analysed. In all, 40.3% of spinal injuries resulted from falls from trees while cutting leaves for fodder, and 27.9% resulted from falls from first/second floors. More than 75% of total spinal injuries are largely preventable. Overall, 46.8% of our spinal injury patients had complete cord transection at the level of injury. All adolescents and adults, irrespective of age or sex, should be the target groups for community education and intervention programmes for prevention of spinal injury.