Selective fecal diversion in complex open pelvic fractures from blunt trauma.

OBJECTIVE: To review the outcomes of patients with open pelvic fractures. DESIGN: Retrospective review of medical records. SETTING: Patients admitted from the injury scene or transferred within 24 hours to a level 1 trauma center. PATIENTS: Thirty-three patients sustaining blunt trauma had pelvic fractures and adjacent wounding. INTERVENTIONS: Treatment protocol that included selective fecal diversion, measures to arrest hemorrhage and prevent wound sepsis, manage associated pelvic injuries, and provide optimal orthopedic outcomes. MAIN OUTCOME MEASURES: Death and sepsis. RESULTS: Exsanguination occurred in one patient and death owing to head injuries occurred in five patients. Wound sepsis occurred in 31% of patients with colostomy and 19% without colostomy. CONCLUSIONS: Management of open pelvic fractures requires a well-coordinated group using several techniques. Selected patients with open pelvic fractures do not require fecal diversion. Incisions for orthopedic surgery should be considered when decisions are made regarding fecal diversion.

The utility of polyglycolic acid mesh for abdominal access in patients with necrotizing pancreatitis.

BACKGROUND: Necrotizing pancreatitis is a poorly understood process that has been treated by a variety of surgical approaches. Despite advances in operative interventions and critical care, this disease often requires prolonged resource allocation and continues to cause substantial morbidity, with mortality rates ranging from 11% to 40%. We report on our recent series of patients with necrotizing pancreatitis and our experience with the use of an absorbable mesh in a subset of these patients to facilitate their surgical care. STUDY DESIGN: From 1985 to 1994, 40 patients with culture-proved necrotizing pancreatitis underwent operative debridement and drainage. Surgical outcomes were compared among patients who underwent a single debridement and drainage, those requiring multiple procedures, and those having placement of polyglycolic acid mesh. RESULTS: The overall hospital mortality rate was 30%. The mean length of hospital stay was 35 days. The rate of infected pancreatic necrosis was 60%, with a mortality rate of 45% in patients having infected pancreatic tissue at surgery. Patients without infected pancreatic tissue at surgery had a mortality rate of 6% (p = 0.03). Eleven patients requiring multiple operations had placement of absorbable polyglycolic acid mesh. Clinic followup was possible in five of six survivors who underwent mesh closure. Abdominal-wall hernias developed in two patients and were repaired electively, and three patients had spontaneous closure by granulation without abdominal-wall hernias. The average number of operations for debridement and drainage was 2.5 (range, 1-15). Patients with limited pancreatic necrosis required a single operative debridement and drainage, and this was associated with improved outcomes. CONCLUSIONS: Necrotizing pancreatitis remains an important challenge in surgical care. It requires prolonged hospitalization, costly resources, and causes substantial morbidity and mortality. Our patients with infected pancreatic necrosis or clinical deterioration underwent open staged necrosectomy and debridement. Those patients requiring repeat laparotomy often had placement of polyglycolic acid mesh. This provided open drainage of the abdominal cavity and simplified further care by allowing easy abdominal access for repeat drainage procedures, often performed in the intensive care unit. These patients had a high rate of fistula formation, which may be decreased by changes in wound care. Polyglycolic acid mesh is a useful adjunct in the surgical care of selected patients with necrotizing pancreatitis.

The management of extrahepatic portal vein aneurysms: observe or treat?

A case of a 70 year old man who was found to have an extrahepatic portal vein aneurysm during an evaluation for hematuria is reported. Extrahepatic portal vein aneurysms are rare with only twenty cases reported in the literature. Typically, patients present with hemorrhage requiring surgical exploration or the aneurysm is discovered during evaluation of another abdominal process. Management includes careful follow-up in the asymptomatic patient without underlying liver disease or portal hypertension.

A decision analysis of traumatic splenic injuries.

We created a decision analysis model of the nonsurgical management of traumatic splenic injuries to clarify the risk of hospital survival, overwhelming postsplenectomy infection (OPSI) deaths, and transfusion-related deaths. We reviewed 72 cases of splenic injury at our institution to identify our transfusion requirements for successful observation (0.5 units), observation failure (1.0 units), and surgical splenic management (1.6 units). Using our model and baseline probabilities determined from the literature, we compared the nonsurgical management of splenic injuries with immediate laparotomy and found an increase in hospital survival with observation, but an over two-fold increase in the risk of transfusion-related death. The OPSI deaths were not markedly different between the two strategies. Overall, we found decision analysis useful in identifying important variables such as the probability of nontherapeutic laparotomy death or missed injury, and in clarifying the risk of the nonsurgical management of splenic injuries with regard to transfusion-related deaths and OPSI deaths.

Local delivery of heparin with balloon angioplasty: results of a prospective randomized trial.

PURPOSE: To evaluate the effectiveness of local delivery of heparin via hydrogel-coated balloons in the treatment of vascular stenoses associated with hemodialysis access. MATERIALS AND METHODS: This was a randomized, prospective trial comparing treatment with hydrogel-coated balloon catheters delivered with heparin coating (n = 33) and without (n = 26). All patients were undergoing hemodialysis, and all stenoses involved the venous anastomosis of a dialysis graft or a native vein. The heparin-treated balloons were soaked in concentrated heparin and delivered in a protected manner to help prevent washout of heparin. RESULTS: The mean primary patencies were 143 days with heparin treatment and 214 days without heparin (P = .174). The mean assisted primary patencies were 165 days with heparin and 194 days without (P = .315). The mean secondary patencies were 351 days with heparin and 384 without (P = .81). CONCLUSION: In this population with this technique, the treatment outcome of venous outflow stenosis in patients with dialysis grafts is not improved with local delivery of heparin.

Laparotomy wound closure with absorbable polyglycolic acid mesh.

A knitted mesh of polyglycolic acid was used successfully in 59 critically ill patients to bridge abdominal wall defects and prevent evisceration after celiotomy. Polyglycolic acid knit mesh was used in 31 patients who had extraordinary visceral edema after resuscitation and the mesh was inserted to avoid excessive tension in the wound closure, 15 patients who had abdominal wall defects after adequate débridement for necrotizing fasciitis, and 13 patients who had losses of abdominal wall tissue caused by trauma or after resection of tumor. There were 14 hospital deaths among the seriously ill patients. Thirteen patients had enterocutaneous fistulas, seven of which occurred after meshes were inserted. The mesh material was strong, pliable and easily inserted in large abdominal wall defects. The polyglycolic acid knit mesh was infiltrated by granulation tissue within three weeks, including in heavily contaminated wounds. Two to three months after insertion, the material was absorbed. Hernia defects were common four to six months after the meshes were inserted and repairs were performed electively after patients had recovered from the primary problems. We conclude that absorbable polyglycolic acid knit mesh can be a useful technique for quickly achieving a secure tension-free closure of abdominal wounds.