Critique of “Sew it Up! A Western Trauma Association Multi-Institutional Study of Enteric Injury Management in the Postinjury Open Abdomen”☆

Background: Use of damage control surgery techniques has reduced mortality in critically injured patients but at the cost of the open abdomen. With the option of delayed definitive management of enteric injuries, the question of intestinal repair/anastomosis or definitive stoma creation has been posed with no clear consensus. The purpose of this study was to determine outcomes on the basis of management of enteric injuries in patients relegated to the postinjury open abdomen. Methods: Patients requiring an open abdomen after trauma from January 1, 2002 to December 31, 2007 were reviewed. Type of bowel repair was categorized as immediate repair, immediate anastomosis, delayed anastomosis, stoma and a combination. Logistic regression was used to determine independent effect of risk factors on leak development. Results: During the 6-year study period, 204 patients suffered enteric injuries and were managed with an open abdomen. The majority was men (77%) sustaining blunt trauma (66%) with a mean age of 37.1 years ± 1.2 years and median Injury Severity Score of 27 (interquartile range = 20–41). Injury patterns included 81 (40%) small bowel, 37 (18%) colonic, and 86 (42%) combined injuries. Enteric injuries were managed with immediate repair (58), immediate anastomosis (15), delayed anastomosis (96), stoma (10), and a combination (22); three patients died before definitive repair. Sixty-one patients suffered intra-abdominal complications: 35 (17%) abscesses, 15 (7%) leaks, and 11 (5%) enterocutaneous fistulas. The majority of patients with leaks had a delayed anastomosis; one patient had a right colon repair. Leak rate increased as one progresses toward the left colon (small bowel anastomoses, 3% leak rate; right colon, 3%; transverse colon, 20%; left colon, 45%). There were no differences in emergency department physiology, injury severity, transfusions, crystalloids, or demographic characteristics between patients with and without leak. Leak cases had higher 12-hour heart rate (148 vs. 125, p = 0.02) and higher 12-hour base deficit (13.7 vs. 9.7, p = 0.04), suggesting persistent shock and consequent hypoperfusion were related to leak development. There was a significant trend toward higher incidence of leak with closure day (χ for trend, p = 0.01), with closure after day 5 having a four times higher likelihood of developing leak (3% vs. 12%, p = 0.02). Conclusions: Repair or anastomosis of intestinal injuries should be considered in all patients. However, leak rate increases with fascial closure beyond day 5 and with left-sided colonic anastomoses. Investigating the physiologic basis for intestinal vulnerability of the left colon and in the open abdomen is warranted.

Contemporary management of stage I testicular seminoma: a survey of Canadian radiation oncologists

Recently published studies clearly indicate that there are now several acceptable options for managing stage i testicular seminoma patients after orchiectomy. We therefore decided to survey Canadian radiation oncologists to determine how they currently manage such patients and to compare the results with previous surveys.

Our results demonstrate that adjuvant single-agent chemotherapy is being considered as an option by an increasing proportion of radiation oncologists (although it is not considered the preferred option), the routine use of radiotherapy is declining, and surveillance is becoming increasingly popular and is recommended most often.

The Preferred Treatment for Stage I Seminoma: A Survey of Canadian Radiation Oncologists

AIMS

To evaluate the preferences of radiation oncologists for managing stage I seminoma.

MATERIALS AND METHODS

An electronic survey evaluating the management of stage I seminoma patients was sent to Canadian radiation oncologists to determine their treatment recommendations and preferences.

RESULTS

The survey completion rate was 74% among eligible respondents (78/105). Most (56%) felt that surveillance was the preferred treatment for patients, whereas 31% thought that adjuvant radiotherapy was best, 1% chose adjuvant chemotherapy as being the preferred option and 12% were unsure. Most would choose the same treatment for themselves if they were diagnosed with stage I seminoma. A previously published survey found that most respondents considered radiotherapy as the best option.

CONCLUSIONS

Most Canadian radiation oncologists now favour surveillance for most stage I seminoma patients.

Evaluating changes in stage I seminoma management: a single institution review

PURPOSE

Historically adjuvant radiotherapy has been routinely recommended for stage I seminoma patients but surveillance has become an increasingly popular option over the last decade. We therefore decided to review the approach currently used by the radiation oncologists at our center.

METHODS

A 14-item questionnaire evaluating physician opinions about treatment options for stage I seminoma patients was developed at the Ottawa Hospital Regional Cancer Centre (OHRCC). It was sent to all the radiation oncologists at OHRCC treating genitor-urinary (GU) malignancies for self-completion.

RESULTS

All the GU radiation oncologists completed the survey for a response rate of 100% (7/7). Most (71%) have been treating GU malignancies for at least 5 years with the median being 9 years. At present, all consider surveillance and adjuvant radiotherapy as standard treatment options for stage I seminoma patients, and recommend these to patients. They give patients information about the treatment options but also give their personal recommendations as well. Most have been routinely discussing surveillance as an option since the late 1990's. Clinical data from the OHRCC confirms that there has been a significant increase in the proportion of stage I seminoma patients being managed by surveillance over the past 15 years. Currently almost half of patients are choosing surveillance.

CONCLUSIONS

There appears to be a fairly uniform approach towards the management of stage I seminoma patients at the OHRCC. Radiation oncologists are now routinely offering both surveillance and adjuvant radiotherapy as reasonable option for these patients, and this is consistent with the recently published literature on this topic.