A 45 year old male underwent full thickness transanal excision of a recurrent rectal villous adenoma. On the evening of surgery he developed an unexplained fever of 38.9°C. Plain X‐rays revealed a significant pneumomediastinum and pneumoretroperitoneum. This was thought to be due to passage of intrarectal air into the mesorectum and extravasation along tissue planes. The patient was managed with restricted fluids by mouth, an antidiarrhoeal agent, intravenous antibiotics, and frequent clinical and radiological observations. During the following 48 hours the fever settled and the pneumomediastinum resolved by the tenth postoperative day. Sigmoidoscopic examination at this time showed a healing rectal wound. This case illustrates a potential consequence of pelvic surgery and emphasizes the extent of the visceral space that exists as a continuum between the pelvis, abdomen, thorax and neck. This is an unusual complication with a dramatic radiological appearance, but one that can be managed successfully with expectation of a completely benign course.
Objective Although sonographic screening for blunt abdominal trauma is gaining acceptance, standards for implementation, training, credentialing, and quality control remain to be established. Design This prospective study examines a Level I trauma service experience with the de novo establishment of a trauma ultrasound (US) program credentialed through the Department of Surgery under the auspices of Continuous Quality Improvement. Materials and Methods All trauma surgeons attended a combined didactic and "hands on" 8-hour trauma US course. Abdominal sonography was subsequently performed on patients with potential blunt abdominal trauma followed by a standard diagnostic evaluation, which included computed tomographic scan, diagnostic peritoneal lavage, or observation. Measurements and Main Results Three hundred patients were studied over a 4-month period. They averaged 35 years of age with an average injury severity score of 12. The time required to perform the US examination averaged less than 3 minutes. Standard diagnostic evaluation included computed tomographic scan (21%), diagnostic peritoneal lavage (45%), and observation (34%). US examinations resulted in 277 true negatives, 17 true positives, two false positives, and four false negatives for a sensitivity of 81.0%, a specificity of 99.3%, and an accuracy of 98.0%. Annualized cost savings with the use of US evaluation versus standard diagnostic evaluation would amount to over $100,000.00. Conclusions This experience with the de novo implementation of a trauma US program suggests that the training and credentialing requirements in this study are sufficient to provide surgeon ultrasonographers with acceptable competence in US diagnosis of blunt abdominal trauma.
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