Prospective evaluation of criteria for the nonoperative management of blunt splenic trauma.

Recent reports have shown an increased mortality associated with the nonoperative management of blunt splenic injury. We have prospectively applied criteria developed from our previous 15-year experience for the nonoperative management (NOM) of blunt splenic injury. These criteria consist of 1) hemodynamic stability on admission or after initial resuscitation with up to two liters of crystalloid infusion, 2) no physical findings or any associated injuries necessitating laparotomy, and 3) a transfusion requirement attributable to the splenic injury of 2 units or less. From 1994 through 2000 a total of 99 patients presented with blunt splenic injury. Thirty-one patients (31%) underwent splenectomy secondary to hemodynamic instability. During the observation period eight of the 68 patients (12%) who initially met criteria for NOM developed hemodynamic instability and underwent splenectomy. All NOM failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the NOM (Group I) or in the group failing NOM (Group II), and no associated morbidities from the splenic injury were seen in either group. No significant differences were seen between Groups I and II in terms of age, gender, mechanism of injury, Injury Severity Score, admitting systolic blood pressure, admitting hemoglobin, transfusion requirements, intensive care unit length of stay, or total hospital length of stay (all P > 0.200). We conclude that established criteria for intervention and careful observation in an intensive care setting for at least 72 hours will minimize morbidity or mortality associated with blunt splenic injury in adults.

Early colectomy may be associated with improved survival in fulminant Clostridium difficile colitis: an 8-year experience.

BACKGROUND: We hypothesized that colectomy for fulminant Clostridium difficile colitis (CDC) before organ failure would be associated with decreased mortality. METHODS: Data were retrospectively collected on patients operated on for CDC between 2000 and 2007. Variables examined included age, sex, immunodeficiency, recurrent CDC, vasopressor requirement, acute respiratory failure, acute renal failure, white blood cell count, and stress ulcer prophylaxis. Univariate and multivariate analyses were performed to identify predictors of mortality. RESULTS: During this period, 6,841 patients were diagnosed with CDC and 69 patients underwent surgery. Independent predictors of mortality were age >65 years (odds ratio [OR] 6.8, confidence interval [CI] 1.4-32.3, P = .016), acute respiratory failure (OR 5.4, CI 1.6-18.1, P = .007), and acute renal failure (OR 3.8, CI 1.1-13.1, P = .035). CONCLUSIONS: Colectomy before the development of organ failure is associated with decreased mortality in patients with fulminant CDC, especially in those >65 years old.

Bladder herniation through suprapubic incision for penile prosthesis.

To our knowledge, we present the first case of bladder herniation after insertion of an inflatable penile prosthesis. A 65-year-old man presented with a suprapubic bulge. He had his third inflatable penile prosthesis placed 1 year earlier. He had no voiding complaints but requested surgical intervention because the hernia was cosmetically undesirable. After the hernia sac was opened the majority of the bladder was found within it. The defect was repaired with Gore-Tex mesh and the reservoir replaced. One must consider bladder involvement in ventral hernias after penile prosthesis insertion, and a preoperative cystogram might assist in identifying hernia contents.