Effectiveness of vacuum-assisted wound closure and mesh-mediated fascial traction in open abdomen management.

PURPOSE: To determine the effectiveness of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) in patients undergoing open abdomen management (OAM). METHODS: Data from cases with OAM for at least five days who were admitted to our institution between January 2011 and December 2020 were included. We compared the patient's age, sex, medical history, indication for initial surgery, APACHE II scores, indication for OAM, operative time, intraoperative blood loss, intraoperative transfusion, success of primary fascial closure (rectus fascial closure and bilateral anterior rectus abdominis sheath turnover flap method), success of planned ventral hernia, duration of OAM, and in-hospital mortality between patients undergoing VAWCM (VAWCM cases, n = 27) and vacuum-assisted wound closure (VAWC) alone (VAWC cases, n = 25). RESULTS: VAWCM cases had a significantly higher success rate of primary fascial closure (70% vs. 36%, p = 0.030) and lower in-hospital mortality (26% vs. 72%, p = 0.002) than VAWC cases. A multivariate logistic regression analysis showed that VAWCM was an independent factor influencing in-hospital mortality (odds ratio, 0.14; 95% confidence interval: 0.04-0.53; p = 0.004). CONCLUSION: VAWCM is associated with an increased rate of successful primary fascial closure and may reduce in-hospital mortality.

Staged Strategy for Early Abdominal Wall Closure in a Case Involving Ruptured Abdominal Aortic Aneurysm Requiring Open Abdomen in Which Primary Fascial Closure was Difficult to Achieve: A Case Report.

Open abdomen is sometimes necessary to save lives after ruptured abdominal aortic aneurysm repair. We report a case in which a staged strategy for early abdominal wall closure was applied to prevent the severe complications due to the extended period of open abdomen. An 81-year-old man with ruptured abdominal aortic aneurysm was transported to our hospital. After the first operation, which required open abdomen, prolonged visceral edema and retroperitoneal hematoma made primary fascial closure difficult. Mesh mediated fascial traction was undergone to reduce the gap in fascial dehiscence under negative pressure wound therapy. However, primary fascial closure could not be accomplished, and abdominal wall reconstruction was performed using bilateral anterior rectus abdominis sheath turnover flap method. Moreover, the skin along the abdominal wall was too tight to be closed primarily. Thus, a bipedicled skin flap was applied. The patient was transferred to another hospital without any remarkable complications. In the present case, the application of a staged closure strategy, which was based on the duration of open abdomenand the condition of the fascia and skin was considered to be important for achieving definitive abdominal closure and preventing the severe complications.

A novel technique for managing open abdomen with the combined use of mesh-mediated traction and the bilateral anterior rectus abdominis sheath turnover flap method: how to do it.

Proper management of abdominal compartment syndrome and open abdomen is important for improving the survival of critically ill patients. However, in cases requiring a prolonged period of open abdomen, it is frequently difficult to perform definitive fascial closure due to lateralization of the abdominal musculature. We herein present a novel combined technique for managing open abdomen. A 74-year-old male with diffuse peritonitis was transferred to our department, after which a long period of open abdomen made it difficult to achieve fascial closure. Polypropylene mesh was sutured to the fascial edges to reduce the gap, which was then serially tightened under negative pressure wound therapy. However, since it was not possible to accomplish definitive fascial closure, abdominal closure was performed using the bilateral anterior rectus abdominis sheath turnover flap method after removing the mesh, without any complications. This combined technique may be an effective alternative in patients requiring open abdomen with subsequent difficulty in achieving definitive fascial closure.

[Role of transcatheter arterial embolization (TAE) for deep renal injury].

PURPOSE: We evaluated usefulness of transcatheter arterial embolization (TAE) for deep renal injury, and investigated whether there is any difference in outcomes for transcatheter arterial embolization (TAE) performed for deep renal injury in a large-sized hospital (university hospital) in comparison with a middle-sized hospital (local hospital). METHODS: We retrospectively reviewed the outcomes of 42 patients with renal injury who were transported to the critical care center of Nippon Medical School (NMS) Hospital in Tokyo from April 2001 to April 2011 and 33 patients of renal injury transported to the critical care center of Ohtawara Red Cross (ORC) Hospital in Tochigi prefecture from April 2001 to April 2009. Therefore, a total of 75 patients, which is the sum of the patients presenting to both the hospitals for renal injury were reevaluated according to the guidelines developed by the Japanese Association for the Surgery of Trauma (JAST) and published in 2008. RESULTS: Forty-two patients in NMS hospital included 6 women and 36 men who were 16 to 88 years old (mean 41.6), and they were divided into Type I (16), Type II (11), and Type III (15) and were treated with bedrest (30), TAE (7), or laparotomy (5). Five patients died, but no one succumbed solely due to the renal injury. On the other hand, 33 Patients in ORC Hospital included 8 women and 25 men who were 16 to 87 years old (mean 46.6). They were divided into Type I (9). Type II (12), and Type III (12) and were treated with bedrest (24) or TAE (9). Eight patients died, but no one succumbed solely due to the renal injury. Sixteen patients were treated successfully with TAE in the 2 hospitals, and 15 of these 16 patients were divided into type III renal injury. Therefore, we believe that nephrectomy should be avoided in such patients because of the benefits offered by TAE. CONCLUSION: TAE was found to be useful for the treatment of type III renal injury in both institutions, irrespective of the size of a hospital.

Delayed stomach necrosis in a patient with injured celiac artery branches after penetrating abdominal trauma.

Injuries of the celiac artery and its branches are rare, but potentially lethal. Ligation of these arteries is performed to control significant hemorrhage. However, few reports have described the adverse effects of ligating these arteries. A 69-year-old woman with a self-inflicted stab wound was brought to our hospital. Her blood pressure could not be measured, therefore aortic cross-clamping was performed, and epinephrine was administered for resuscitation, an emergency laparotomy was performed, and the roots of splenic artery and common hepatic artery were ligated. The left gastric artery which was anomalous and arose directly from the aorta, was also injured and had to be ligated. Norepinephrine was required after the surgery. Enhanced computed tomography performed on hospital day 4 revealed a disrupted celiac artery. The patient developed gastric necrosis on hospital day 23 and, hence, underwent total gastrectomy was performed. The possibility of delayed stomach necrosis should be considered during the postoperative management of patients who undergo ligation of all of the celiac artery branches and experience global hypoperfusion after the surgery.

Successful multidisciplinary management of vascular Ehlers-Danlos syndrome.

Vascular Ehlers-Danlos syndrome is a rare connective tissue disease with a high risk of severe complications. Because of these complications, the median life expectancy for patients with vascular Ehlers-Danlos syndrome is estimated at 48 years. However, the optimal management of these complications remains unclear. A 25-year-old man with abdominal pain was transported to our hospital by ambulance. He had undergone Hartmann's operation at 22 years of age for a first-time colonic perforation. At that time, a genetic test revealed germline variants in COL3A1, which encodes type III procollagen; therefore, the patient was diagnosed with vascular Ehlers-Danlos syndrome. When the patient presented to our hospital, we suspected another colonic perforation and thus performed an emergency operation. Open abdominal management, transcatheter arterial embolization, and negative-pressure wound therapy were performed as life-saving measures. Notably, these procedures should initially be avoided in patients with vascular Ehlers-Danlos syndrome because of tissue fragility. Open abdominal management, transcatheter arterial embolization, and negative-pressure wound therapy may be useful for patients with vascular Ehlers-Danlos syndrome who develop panperitonitis and massive intra-abdominal bleeding.

Portal Venous Gas in Adults: Clinical Significance, Management, and Outcomes of 25 Consecutive Patients.

BACKGROUND: Portal venous gas (PVG) is a rare finding and has a grave prognosis. The most common and critical underlying pathology of PVG is bowel necrosis. However, bowel necrosis is sometimes difficult to accurately diagnose. We retrospectively analyzed data from patients that contributed to the decision to perform emergency surgery and bowel resection. METHODS: Between 2009 and 2019, 25 consecutive adult patients with PVG were identified retrospectively and divided into the Operation and Non-operation groups. The Operation group was further subdivided into the Bowel resection and Non-resection groups. Clinical, laboratory, and radiographic variables were analyzed. RESULTS: Conservative management was successful for 32% (8/25) of patients (Non-operation group: mortality 0%); 68% (17/25) were treated surgically (Operation group: mortality 35.3%). In the Operation group, 52.9% (9/17) underwent bowel resection (Bowel resection group: mortality 55.6%); however, bowel resection was unnecessary in 47.1% (8/17) of cases (Non-resection group: mortality 12.5%). Univariate analysis revealed significant differences between the Operation and Non-operation groups in GCS, APACHE II, abdominal distention, CRP, lactate, and CT findings of bowel dilatation, pneumatosis intestinalis, and attenuation of contrast effects of the bowel wall. However, with the exception of GCS, there was no significant difference between the Bowel resection and Non-resection groups. CONCLUSIONS: Analysis of clinical, laboratory, and radiographic variables can inform decisions on conservative management. However, 47.1% of the present patients who underwent surgery for suspected bowel necrosis did not require bowel resection, suggesting that this approach alone may not be sufficient to avoid non-therapeutic laparotomy. A new approach should be developed to improve this situation.

Nonocclusive mesenteric ischemia associated with a hyperosmolar hyperglycemic state: Hepatic portal venous gas as an indicator of mesenteric ischemia.

BACKGROUND: The diagnosis of nonocclusive mesenteric ischemia (NOMI) is always challenging in critically ill patients. Herein, we aimed to report a case of NOMI associated with a hyperosmolar hyperglycemic state (HHS). A small amount of hepatic portal venous gas (HPVG) triggered the diagnosis of NOMI. CASE PRESENTATION: A 77-year-old man was transferred due to shock and disorder of consciousness. He was diagnosed with an HHS. We suspected intestinal ischemia due to a small amount of HPVG revealed by computed tomography (CT). Peritoneal signs were revealed after treatment for the HHS. Computed tomography was carried out again 5 h after admission, which showed a large amount of HPVG, remarkable bowel dilatation, and pneumatosis intestinalis. We performed an emergency laparotomy and resected the small bowel necrosis resulting from NOMI. CONCLUSION: An HHS can cause NOMI, and the presence of HPVG on CT is an important finding that suggests mesenteric ischemia, even in small amounts.

Metformin, an antidiabetic agent, suppresses the production of tumor necrosis factor and tissue factor by inhibiting early growth response factor-1 expression in human monocytes in vitro.

Metformin, an antidiabetic agent, has been shown to reduce atherothrombotic disease in diabetic patients independent of antihyperglycemic effect. Recent studies have demonstrated that metformin attenuates the proinflammatory responses in human vascular wall cells and macrophages. However, the detailed molecular mechanisms underlying these therapeutic effects remain unclear. In the present study, we investigated the effects of metformin on tumor necrosis factor (TNF) production and tissue factor (TF) expression in isolated human monocytes stimulated with lipopolysaccharide (LPS) or oxidized low-density lipoprotein (oxLDL). Metformin significantly inhibited both TNF production and TF expression in isolated human monocytes stimulated with LPS or oxLDL. Metformin also significantly inhibited TNF and TF mRNA in human monocytes stimulated with LPS. Although metformin did not inhibit the activation of either nuclear factor-kappaB or activator protein-1, it inhibited the expression of early growth response factor-1 (Egr-1) and phosphorylation of extracellular signal-regulated protein kinase (ERK) 1/2 in monocytes stimulated with LPS or oxLDL. These results suggest that metformin may attenuate the inflammatory responses, at least in part, by suppressing the production of both TNF and TF through the inhibition of the ERK1/2-Egr-1 pathway in human monocytes.

Delayed development of portal vein thrombosis in a patient initially detected with portal venous gas and pneumatosis intestinalis: a case report.

BACKGROUND: Portal venous gas (PVG) and pneumatosis intestinalis (PI) are rare pathologic findings, and a delayed appearance of portal vein thrombosis (PVT) in such patients is extremely rare. CASE PRESENTATION: A 51-year-old man complaining of epigastric pain was referred to our hospital. Computed tomography (CT) at admission revealed massive PVG and extensive PI, but no PVT. Emergency laparotomy was carried out, but bowel resection was unnecessary. On follow-up CT on postoperative day 5, thrombosis was noted in the portal venous system, and anticoagulant was started immediately. This patient was discharged and continued to take the anticoagulant. Seven months after discharge, PVT had disappeared on CT without any thromboembolic complications. CONCLUSION: If acute PVT is detected, anticoagulant is needed to prevent bowel ischemia and/or portal hypertension due to the growth of the thrombus. Clinicians should be aware of the potential for such a complication, and make their best efforts to exclude this entity using CT or sonography.

The long-term outcomes of early abdominal wall reconstruction by bilateral anterior rectus abdominis sheath turnover flap method in critically ill patients requiring open abdomen.

Background: In a previous study, we reported the usefulness of early abdominal wall reconstruction using bilateral anterior rectus abdominis sheath turnover flap method (turnover flap method) in open abdomen (OA) patients in whom early primary fascial closure was difficult to achieve. However, the long-term outcomes have not been elucidated. In the present study, we aimed to evaluate the procedure, particularly in terms of ventral hernia, pain, and daily activities. Methods: Between 2001 and 2013, 15 consecutive patients requiring OA after emergency laparotomy and in whom turnover flap method was applied were retrospectively identified. The long-term outcomes were evaluated based on medical records, physical examinations, CT imaging, and a ventral hernia pain questionnaire (VHPQ). Results: The turnover flap method was applied in 2 trauma and 13 non-trauma patients.In most of cases, primary fascial closure could not be achieved due to massive visceral edema. The turnover flap method was performed for abdominal wall reconstruction at the end of OA. The median duration of OA was 6 (range 1-42) days. One of the 15 patients died of multiple organ failure during initial hospitalization after the performance of the turnover flap method. Fourteen patients survived, and although wound infection was observed in 3 patients, none showed enteric fistula, abdominal abscess, graft infection, or ventral hernia during hospitalization. However, it was found that 1 patient developed ventral hernia during follow-up at an outpatient visit. Nine of 14 patients were alive and able to be evaluated with a VHPQ (follow-up period: median 10 years; range 3-15 years). Seven out of nine patients were satisfied with this procedure, and none complained of pain or were limited in their daily activities. Conclusions: Based on the results of this study, early abdominal reconstruction using the turnover flap method can be considered to be safe and effective as an alternative technique for OA patients in whom primary fascial closure is considered difficult to achieve.

Early Transcatheter Arterial Embolization for the American Association for the Surgery of Trauma Grade 4 Blunt Renal Trauma in Two Institutions.

OBJECTIVES: To evaluate the efficacy of early transcatheter arterial embolization for hemodynamically stable patients with The American Association for the Surgery of Trauma (AAST) grade 4 blunt renal trauma. MATERIALS AND METHODS: The medical records of consecutive patients with grade 4 blunt renal trauma who were transported to our two critical care centers in Japan and treated with early transcatheter arterial embolization (TAE) between 2001 and 2013 were retrospectively reviewed. Treatment failure was defined as the need for further surgical intervention or re-embolization after initial embolization. We divided these cases into two groups, a group who survived and a group who died, investigating the factors that led to death. RESULTS: Seventeen patients underwent early TAE, with an average time between presentation and embolization for renal trauma of 125 minutes (66-214 minutes). There was no case of treatment failure. Three of the patients died, but none solely because of renal injury. Significant factors associated with patient death were the number of concomitant injured organs (p=0.04), the presence of pelvic fractures (p<0.01), and the presence of visceral injuries (p<0.01). The presence of lumber fractures (p=0.09) also tended to be associated with patient death. CONCLUSIONS: Early TAE is an effective treatment and should be actively performed for hemodynamically stable patients with grade 4 blunt renal injuries without multiple concomitant organ injuries.

Activation of sensory neurons contributes to reduce spinal cord injury in rats.

We previously demonstrated that activation of sensory neurons increases endothelial prostaglandin I(2) (PGI(2)) production by releasing calcitonin gene-related peptide (CGRP). Since PGI(2) reduces post-traumatic spinal cord injury (SCI) by inhibiting tumor necrosis factor (TNF) production, activation of sensory neurons in the spinal cord tissue may ameliorate spinal cord injury. This study examines these possibilities using rat models of compression trauma-induced SCI. Both SB366791, a specific vanilloid receptor antagonist, and CGRP (8-37), a CGRP receptor antagonist, significantly inhibited trauma-induced increases in spinal cord tissue 6-keto-PGF(1alpha) levels. SB366791, CGRP (8-37) and indomethacin (IM) enhanced increases in spinal cord tissue TNF levels at 2h after trauma and exacerbated motor disturbances. Administration of CGRP significantly reduced motor disturbances and inhibited increases in spinal cord tissue TNF levels through enhancement of increases in tissue levels of 6-keto-PGF(1alpha). These observations strongly suggest that activation of sensory neurons might ameliorate compression trauma-induced SCI, inhibiting TNF production through enhancement of endothelial PGI(2) production. Thus, although the spinal cord sensory neurons function as nociceptive neurons, they could also be critically involved in the cytoprotective system that attenuates SCI development and, thus, pharmacological stimulation of spinal cord sensory neurons might contribute to reduce spinal cord injury.

Administration of capsaicin and isoflavone promotes hair growth by increasing insulin-like growth factor-I production in mice and in humans with alopecia.

OBJECTIVE: Insulin-like growth factor-I (IGF-I) plays an important role in hair growth. Capsaicin activates vanilloid receptor-1, thereby increasing the release of calcitonin gene-related peptide (CGRP) from sensory neurons, and CGRP has been shown to increase IGF-I production. We recently reported that isoflavone, a phytoestrogen, increases production of CGRP by increasing its transcription in sensory neurons. These observations raise the possibility that administration of capsaicin and isoflavone might promote hair growth by increasing IGF-I production. In the present study, we examined this possibility in mice and humans with alopecia. DESIGN: Dermal IGF-I levels, immunohistochemical expression of IGF-I in the skin and hair regrowth were examined after capsaicin and isoflavone administration to wild-type (WT) mice and CGRP-knockout mice. Plasma levels of IGF-I and promotion of hair growth were evaluated in 48 volunteers with alopecia after administration of capsaicin and isoflavone for 5 months. RESULTS: Subcutaneous administration of capsaicin significantly increased dermal IGF-I levels at 30 min after administration in WT mice (p < 0.01), but not in CGRP-knockout mice. Dermal levels of IGF-I were significantly higher in WT mice administered capsaicin and isoflavone for 4 wks than in those administered capsaicin alone for 4 wks (p < 0.01) and in those administered neither of them (p < 0.01). Immunohistochemical expression of IGF-I at dermal papillae in hair follicles was increased in WT mice administered capsaicin and isoflavone and in those administered capsaicin alone at 4 wks. Hair regrowth was clearly more accelerated in WT mice administered capsaicin and isoflavone for 4 wks than in those administered capsaicin alone for 4 wks and in those administered neither of them. Plasma levels of IGF-I were significantly increased from baseline levels in 31 volunteers with alopecia at 5 months after oral administration of capsaicin (6 mg/day) and isoflavone (75 mg/day) (p < 0.01), while they were not increased in 17 volunteers with alopecia administered placebo. The number of volunteers with alopecia who showed promotion of hair growth at 5 months after administration was significantly higher among volunteers administered capsaicin and isoflavone (20/31: 64.5%) than among those administered placebo (2/17: 11.8%) (p < 0.01). CONCLUSIONS: These observations strongly suggested that combined administration of capsaicin and isoflavone might increase IGF-I production in hair follicles in the skin, thereby promoting hair growth. Such effects of capsaicin and isoflavone might be mediated by sensory neuron activation in the skin.

Contribution of sensory neurons to sex difference in the development of stress-induced gastric mucosal injury in mice.

BACKGROUND & AIMS: Sensory neurons play a critical role in reducing stress-induced gastric mucosal injury by releasing calcitonin gene-related peptide (CGRP) through an increase in gastric mucosal levels of prostacyclin (PGI(2)). Because estrogen enhances nerve growth factor-mediated CGRP production in sensory neurons, we hypothesized that stress-induced gastric mucosal injury occurs less in females than in males. METHODS: Gastric ulcer index, gastric myeloperoxidase activity, and gastric tissue levels of CGRP and 6-keto-PGF(1alpha), a stable metabolite of PGI(2), were determined in male and female wild-type (CGRP(+/+)) mice and CGRP knockout (CGRP(-/-)) mice subjected to water-immersion restraint stress. RESULTS: In CGRP(+/+) mice, ulcer index and myeloperoxidase activities were lower and gastric tissue levels of CGRP and 6-keto-PGF(1alpha) were higher in female mice than in male mice, but there were no such sex differences in CGRP(-/-)mice. Sex differences in CGRP(+/+) mice were eliminated by pretreatment with SB366791 (500 microg/kg intraperitoneally), a vanilloid receptor antagonist, and by ovariectomy. Reversal of sex differences by ovariectomy was not observed in female CGRP(+/+) mice with estradiol replacement (1 mg . kg(-1). wk(-1) for 3 weeks). Levels of CGRP messenger RNA in dorsal root ganglion neurons isolated from female CGRP(+/+) mice were decreased by ovariectomy, and these decreases were reversed by estradiol replacement. CONCLUSIONS: Estrogen-mediated increases in CGRP levels in sensory neurons might contribute to reduce stress-induced gastric mucosal injury by attenuating inflammatory responses. This might at least partly explain the sex difference observed in the development of stress-induced gastric mucosal injury in mice.

The role of interventional radiology in patients requiring damage control laparotomy.

BACKGROUND: Interventional angiography has been used as a less invasive alternative to surgery to control hemorrhage resulting from trauma. This retrospective study analyzed the role of interventional radiology in patients requiring damage control laparotomy. METHODS: Twenty patients underwent damage control laparotomy between January 1994 and May 2001. Eight of the 20 patients also underwent angiographic evaluation and treatment before or after the damage control laparotomy. RESULTS: Three patients underwent angiography before damage control laparotomy, because a large, pelvic retroperitoneal hematoma was seen on computed tomographic scan, and the amount of intraperitoneal blood seemed insufficient to account for the magnitude of the patient's hemodynamic instability. Five patients underwent angiography after damage control laparotomy. The indication was a nonexpanding retroperitoneal hematoma in three patients, a nonexpanding hepatic hilar hematoma in one patient, and a hepatic injury associated with cirrhosis in one patient. Lumbar artery injuries were identified and treated by embolization in three patients. Four of the eight patients who underwent both damage control laparotomy and angiography survived. CONCLUSION: Angiography before damage control laparotomy may be indicated to control retroperitoneal pelvic hemorrhage in hemodynamically unstable patients who have insufficient intraperitoneal blood loss to account for their hemodynamic instability. Angiography after damage control laparotomy should be considered when a nonexpanding, inaccessible hematoma is found at operation in a patient with a coagulopathy.