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Background: Venous thromboembolism (VTE) in patients with major pelvic fractures who undergo preperitoneal pelvic packing (PPP) has not been investigated. We hypothesized that patients who undergo PPP are at high risk for VTE, thus early prophylactic anticoagulation and screening duplex are warranted., Study Design: All patients requiring PPP from 2015 to 2019 were reviewed. Management and outcomes were analyzed., Results: During the study period, 79 patients underwent PPP. Excluding the early deaths, 17 patients had deep venous thrombosis (DVT) and 6 had pulmonary emboli (PE); 4 patients had both DVT/PE. Overall mortality was 15%. Thirty-two patients underwent screening duplex within 72 h of admission and 10 were positive for DVT., Conclusion: Patients with complex pelvic trauma undergoing PPP have a 23% incidence of DVT and an additional 8% incidence of PE. 31% of screening ultrasounds are positive. The overall mortality was 15%. With a high incidence of VTE in this patient population, we recommend screening duplex ultrasounds., (Copyright © 2020. Published by Elsevier Inc.)

Background: Most blunt splenic injuries (BSI) are treated with nonoperative management (NOM) or embolization (EMBO). Little is known about the hematologic changes associated with these treatments. We aim to assess the temporal changes of hematologic markers in trauma patients who undergo splenectomy (SPL), packing and splenorrhaphy (P/S), EMBO, or NOM. We hypothesize that differences in trends of hematologic markers exist in patients undergoing EMBO or SPL, compared to NOM., Methods: An 8-year review of adult patients with BSI and underwent SPL, EMBO, P/S, or NOM. White blood cell count (WBC), hematocrit (HCT) and platelet count (PLT) at presentation to 14 days post-admission were analyzed; post-procedural complications were reviewed. Temporal trends were compared using linear mixed-effects models., Results: 478 patients sustained BSI, 298 (62.3%) underwent NOM, 100 (29.2%) SPL, 42 (8.8%) EMBO, and 38 (8.0%) P/S. After adjustment for age, ISS and splenic injury grade, SPL patients had a significantly higher upward trend compared to other management strategies (p < 0.05). Infection further increased this trend. Starting on day 6, SPL patients with infections had significantly higher WBC than those without infection. SPL and P/S were more likely than NOM to develop infections after adjustment for confounders (HR = 3.64; 95%CI: 1.79-7.39 and HR = 2.59; 95%CI: 1.21-5.55, respectively). Day 6 WBC>16,000 cells/ml post-SPL had a positive predictive value (PPV) of 65.2% and negative predictive value (NPV) of 76.9% for infections. Among P/S, Day 6 WBC >10,200 cells/ml had a PPV = 50% and NPV = 86.7% for infections., Conclusions: We observed distinct patterns of hematologic markers following BSI managed with SPL, EMBO, P/S, and NOM. Day 6 WBC increases after SPL or P/S should raise suspicion of infections and trigger a diagnostic investigation., Competing Interests: Declaration of competing interest The manuscript has been submitted solely to this journal and has not previously been published in any form in another publication. The authors have no conflicts of interest related to this manuscript., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Burnout and depression is higher in trauma surgeons as compared to surgeons in other specialties. Clinical practice for many acute care surgeons (ACS) includes in-house call (IHC). The goal of this study was to quantitate physiologic stress among ACS who take IHC., Methods: ACS with IHC responsibilities from two Level I trauma centers were studied. Participants wore a fitness and heart rate variability (HRV) device over 3 months. HRV was categorized as normal if 85% of baseline, moderate stress when HRV <85% but >50%, and high stress when HRV< 50%., Results: 1421 nights were recorded among 17 surgeons (35.3% female; mean age 45.5 years). Excluding IHC, mean HRV = 32.23, and 95.63% of days were consistent with moderate or high stress. Post-call day 2 had significantly highest percentage of high stress (65.82%, p = 0.0495). High and moderate stress levels returned to baseline on post-call day 3., Conclusions: High and moderate stress beyond IHC is common among ACS. Future study is needed to determine consequences of persistent stress and identify factors which impact recovery after IHC., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Recovery of upper aerodigestive tract function after reconstruction of segmental oromandiblectomy defects is frequently incomplete. The purpose of this study was to quantitate postreconstruction function and define variables that predict functional outcome in this population., Methods: A prospective study of 21 patients who underwent microvascular free tissue transfer reconstruction of segmental oromandibular defects was performed. Measures of swallowing, speech, bite, and oral intake were performed preoperatively and at 1, 3, 6, and 12 months postoperatively or until plateau. Preoperative versus maximal postoperative measures were compared and correlated with nine potentially predictive variables. Univariate and multivariate analyses were performed to determine the most significant predictive factors., Results: Baseline function in the study population was abnormal. Postoperative bite force improved, but swallowing, speech, and oral intake were worse than preoperative. Significant (univariate) predictors of outcome included diagnosis of cancer, tongue resection, pharynx resection, and flap skin paddle area. Only tongue resection remained significant in multivariate analysis., Conclusions: Increasing need for oropharyngeal lining replacement, especially after tongue resection, is the most important predictor of functional outcome in reconstruction of segmental mandible defects.

Background: When lower lip incisions are combined with anterior oromandibular resection and composite flap reconstruction, increased potential exists for abnormal healing of the lower lip. The aim of this study is to describe these deformities and operative techniques for their correction., Methods: A retrospective review of all patients undergoing oromandibular reconstruction with osteocutaneous free tissue transfer at Indiana University Medical Center and Affiliated Hospitals during the 5-year period between January 1991 and 1996 was performed. Patients requiring secondary lower lip revision or repair were identified. Patient characteristics, lip deformities, and operative correction techniques were detailed., Results: Sixty patients underwent 62 free tissue transfers for oromandibular reconstructions. Five patients (7.1%) required reoperation for lower lip deformities related to abnormal wound healing. All affected patients had lower lip split incisions for access to the oropharynx and composite anterior floor of mouth and mandibular resection and reconstruction. Each patient had successful repair of the lower lip deformity and correction of related functional deficits using lower lip tissue., Conclusion: Lower lip deformities occur in a subset of patients undergoing anterior mandibular reconstruction. Horizontally redundant lower lip tissue can be mobilized to repair the secondary aesthetic and functional deficits.

Microvascular free tissue transfer has provided a variety of methods of restoring vascularized bone and soft tissue to difficult defects created by tumor resection and trauma. Over 7 years, 26 patients have undergone 28 free flaps for mandibular reconstruction, 15 for primary squamous cell carcinoma of the floor of the mouth or tongue, 7 for recurrent tumor, and 6 for other reasons [lymphangioma (1), infection (1), gunshot wound (1), and osteoradionecrosis (3)]. Primary reconstruction was performed in 19 cases and secondary in 9. All repairs were composite flaps including 12 scapula, 5 radial forearm, 3 fibula, 2 serratus, and 6 deep circumflex iliac artery. Mandibular defects included the symphysis alone (7), symphysis and body (5), symphysis-body-ramus condyle (2), body or ramus (13), and bilateral body (1). Fourteen patients had received prior radiotherapy to adjuvant or curative doses. Eight received postoperative radiotherapy. All patients had initially successful vascularized reconstruction by clinical examination (28) and positive radionuclide scan (22 of 22). Bony stability was achieved in 25 of 26 patients and oral continence in 24 of 26. One complete flap loss occurred at 14 days. Complications of some degree developed in 22 patients including partial skin necrosis (3), orocutaneous fistula (3), plate exposure (1), donor site infection (3), fracture of reconstruction (1), and fracture of the radius (1). Microvascular transfer of bone and soft tissue allows a reliable reconstruction--despite previous radiotherapy, infection, foreign body, or surgery--in almost every situation in which mandible and soft tissue are absent. Bony union, a healed wound, and reasonable function and appearance are likely despite early fistula, skin loss, or metal plate or bone exposure.

To determine the incidence and types of infections in Hodgkin's disease, particularly those related to the overwhelming pneumococcal sepsis syndrome, 210 consecutive patients with previously untreated Hodgkin's disease who underwent staging laparotomy with splenectomy from March 1968 to October 1979 were reviewed. For 178 patients (85 percent) alive at the end of the study, the mean follow-up time was 68.1 months. Eighty-two serious infections occurred among 59 (28 percent) of the patients; 47 (57 percent) serious infections were microbiologically documented and 35 (43 percent) were clinically documented. Forty-seven microbiologically documented serious infections occurred in 34 patients and consisted of 23 episodes of pneumonia, 10 cases of bacteremia, seven wound infections, two cases of disseminated herpes zoster, one subphrenic abscess, and four miscellaneous infections. Microbiologically documented serious infections occurring during initial treatment or remission had lower incidences of leukopenia (29 versus 58 percent) (p = 0.09) and death (11 versus 53 percent) (p = 0.005) than those occurring after relapse of Hodgkin's disease. Of the microbiologically documented serious infections, 76 percent were associated with a predisposing factor(s) (leukopenia, postoperative state, steroids, peripheral neuropathy, leukemia), of which 34 percent were fatal. Microbiologically documented serious infections unassociated with a predisposing factor were never fatal, including the only episode of pneumococcal sepsis in the series. In contrast to microbiologically documented serious infections, only 14 percent of clinically documented serious infections (versus 38 percent) were fatal. The overwhelming pneumococcal sepsis syndrome and other infections thought to be associated with the asplenic state are uncommon problems in patients with Hodgkin's disease after splenectomy.

The development of oropharyngocutaneous fistulas after resection of the head and neck is a major cause of morbidity. In this retrospective review, we examined the role of radiotherapy and musculocutaneous flaps in the development and management of fistulas and found several significant factors associated with these fistulas. In patients with this complication, there is a significant decrease in postoperative hemoglobin and albumin levels and absolute lymphocyte counts. In addition, there is a significant reduction in lymphocyte counts in the irradiated patient. Musculocutaneous flaps play an invaluable role in the management of fistulas. In the irradiated patient, the healing of fistulas is a long and difficult process; the presence of a musculocutaneous flap is the only significant factor in the ability of the fistulas to heal spontaneously. If the fistulas are to close spontaneously, they will do so within 4 to 6 weeks. Fistulas that develop in the absence of a previously placed musculocutaneous flap are more severe than if a vascularized flap were present initially. Successful management of such fistulas is enhanced by use of vascularized extracervical tissue.

The platysma musculocutaneous flap was used in 14 patients for reconstruction of the oral lining and external skin coverage in the head and neck area. Complications occurred in five patients. Only one patient, however, required further surgery and this was for correction of a poor cosmetic result. The skin and subjacent muscle are supplied by a major vascular pedicle from the facial artery and vein and a minor pedicle from the transverse cervical artery and vein. Either pedicle can be used as the pivot for the flap's arc of rotation. The donor defect can be closed primarily and did not present any problems. The flap can be raised with both its motor and sensory supply intact. The thinness and pliability, color match, and proximity make this flap a useful adjunct in head and neck surgery.

Retrospective analysis by chart review, personal interview, and physical examination identified 88 patients who received 96 jejunal free flaps over a 10 year period. Seventy-nine of these patients had cancer. There were 13 operative failures (13.5 percent) in 10 patients. Failures were attributed to arterial thrombosis in four instances, venous anastomotic problems in four instances, fistula and infection in the neck in one instance, carotid blowout in one instance, psychosis with avulsion in one instance, and an unknown cause in two instances. Seven second attempts at salvage of jejunal flaps were performed with five successes. There were five deaths in the perioperative period (6 percent). Of these, one was directly attributed to graft failure. The following eight abdominal complications required operation: wound dehiscence (four instances), small bowel obstruction (one instance), Mallory-Weiss tear (one instance), gastrostomy tube leak (one instance), and acute gastric dilatation (one instance). Complications in the neck included infection (six instances), infection requiring operation (three instances), hematoma (three instances), and suture line dehiscence (one instance). Fistulas developed in 28 patients (32 percent), 12 of whom required operative closure (43 percent). Significant stenosis developed in six patients, two of whom required operative revision. Of 79 patients treated for cancer, 34 died from progression of disease which recurred an average of 9.7 months postoperatively. Death ensued an average of 16.7 months postoperatively. Ten patients died with no evidence of disease. At last follow-up, 28 patients were alive without apparent disease. Twenty-six of these patients have good swallowing function. Significant palliation and a high rate of restoration of function are possible with the free jejunal autograft. Careful patient selection should markedly decrease operative morbidity and mortality.

The efficacy of total glossectomy for advanced carcinoma of the tongue remains controversial. A retrospective chart review was undertaken to evaluate the oncologic and functional results in 17 consecutive patients who underwent this procedure. There were two patients with stage III disease, eight with stage IV disease, and seven with recurrent disease. The larynx was preserved in seven patients. One patient required a secondary laryngectomy. All patients were reconstructed immediately, 11 with a pectoralis major myocutaneous flap and 6 with free-tissue transfer. The operative mortality was 6 percent; the morbidity was 59 percent. At last follow-up, 53 percent of the patients were alive without disease, with a mean disease-free survival period of 36 months. Ninety-three percent of the patients regained swallowing and independent oral alimentation; 80 percent of those with laryngeal preservation regained intelligible speech. We have concluded that total glossectomy should be considered as a primary modality for advanced carcinoma of the tongue and not solely reserved for salvage in hopeless situations. With or without laryngectomy, excellent survival and functional results can be obtained.

Two hundred ten patients were retrospectively studied to evaluate the risk of appendectomy performed during laparotomy for staging of Hodgkin's disease. Seventy-nine patients did not have their appendix removed, and a wound infection developed in 1. One hundred thirty-one patients had an appendectomy, and 7 wound infections occurred in this group. This difference was not statistically significant. No patient died as a consequence of their wound infection, and no intraabdominal infections occurred. Our data suggest that the risk for development of a wound infection after a staging laparotomy for Hodgkin's disease is increased by performing an incidental appendectomy as part of the procedure. Although the differences noted were not statistically significant, this was probably due to the sample size. Based on our data, we do not routinely remove the appendix at the time of staging laparotomy.

Forty-three patients with major three-dimensional orbitomaxillary defects underwent 48 free-tissue transfers for defects arising from resection of a neoplasm or trauma. Defects were complex, involving the malar skin, mandible, lateral nasal wall, orbit, palate, and brain. A three-dimensional approach attempting to recreate the midface by folding the flaps was the usual method, with subsequent revisions if necessary. Ten patients had simultaneous free bone grafts and 6 had vascularized bone grafts. There were three flap failures and four perioperative deaths. Excluding the 4 deaths, the results were assessed as excellent in 25 patients, good in 12, and poor in 2. Free-tissue transfer is a reliable method of providing enough tissue at one initial operation to satisfy complex three-dimensional defects of the orbitomaxillary region. Followed by minor revision, it provides a means of restoring function and appearance without multiple staged procedures with a high risk of failure.