Results of emergency colectomy in nonagenarians and octogenarians previously labeled as prohibitive surgical risk.

PURPOSE: There are no standardized criteria for what constitutes prohibitive risk for emergency abdominal surgery. METHODS: A retrospective review was performed comparing two groups of patients having emergent colectomy. One group had previously been labeled as being prohibitive surgical risk and the other was a contemporary, non-prohibitive risk group also requiring emergency colectomy. All operations were performed by a single surgeon. RESULTS: There were 27 prohibitive risk patients and 81 non-prohibitive risk (control group) patients. The average age of the prohibitive risk group was 85 years (range 78-99) compared to the control group mean age of 52 years (18-79, p < 0.00001). Prohibitive risk was due to extremes of age combined with congestive heart failure in 44%, followed by chronic obstructive pulmonary disease combined with heart failure in 19%. The groups were closely matched by the type of colectomy performed. The total complication rate was much higher in the prohibitive risk group compared to the non-prohibitive risk patients (81% versus 48%, p 0.005). But the 30-day mortality rate was similar between groups (7% versus 4%, p 0.6). CONCLUSION: Patients who are labeled as prohibitive surgical risk may be inaccurately assessed in the majority of cases. Additional research will need to be performed to evaluate the presence of quantifiable high-risk physiological conditions, and not just comorbidities, that place a patient at high risk of death after abdominal surgery. Until then, elderly patients should not be denied colectomy based upon comorbidities alone.

A Comparison of Endoscopic Versus Surgical Creation of a Cystogastrostomy to Drain Pancreatic Pseudocysts and Walled-Off Pancreatic Necrosis in 5500 Patients.

Objective: To determine the success, morbidity, and mortality rates of endoscopic and surgical creation of pancreatic cystenterostomies for the drainage of peripancreatic fluid collections, pseudocysts with necrotic debris, and walled-off pancreatic necrosis. Summary Background Data: Endoscopic methods of cystenterostomy creation to drain pancreatic pseudocysts (with and without necrotic debris) and infected peripancreatic fluid collections are perceived to be less morbid than surgery. Contemporary reports document a very high complication rate with endoscopic methods. Methods: A meta-analysis of 5500 patients. Results: Open and laparoscopic surgical techniques to drain chronic pancreatic pseudocysts, infected pancreatic fluid collections, and walled-off pancreatic necrosis are more successful with less morbidity and mortality than endoscopic methods. Conclusions: In regards to a surgical step-up approach to treat chronic infected pancreatic fluid collections or walled-off pancreatic necrosis, surgical creation of a cystenterostomy is more successful with fewer complications than endoscopic methods and should be given priority if less invasive or conservative methods fail.

Acute fulminant necrotizing mesenteric lymphadenitis causing bowel ischemia.

This case report documents the medical progression of a 56-year-old man who presented with a small bowel obstruction and was found to have acute fulminant necrotizing mesenteric lymphadenitis causing small intestinal ischemia. A large portion of the proximal jejunal mesentery was necrotic with vascular thrombosis leading to small bowel ischemia and obstruction. He was successfully managed surgically and survived. The evaluation and possible aetiologies are discussed.

The Dudley colectomy in urgent and emergent situations: a 10 patient case series.

Left-sided colon pathology that needs to be treated in an emergency situation usually requires a partial colectomy and colostomy with a Hartmann's pouch. Primary anastomosis is avoided with an unprepped left colon due to the risk of post-operative anastomotic leakage. In this series, 10 patients were treated with on-table lavage to wash out the colon, and left colectomy with primary anastomosis in urgent and emergent situations without a protective ileostomy (the Dudley colectomy). All patients acutely recovered and none had an anastomotic leak. There was a single superficial wound infection, and a single late mortality due to heart failure. On-table colonic lavage and left colectomy with primary anastomosis without a protective ileostomy is a safe and effective way to treat left-sided colon emergencies without a protective ileostomy.

Role of Fish Oil in Post-Cardiotomy Bleeding: A Summary of the Basic Science and Clinical Trials.

BACKGROUND: Omega-3 fatty acids are widely used. This article reviews the coagulopathic effects of fish oil. METHODS: A review was performed of all English articles that addressed the topic from 1980 to 2017. RESULTS: Fish oil induces an in vitro coagulopathy in humans due to inhibitory effects in platelet-to-platelet adhesion and platelet-stimulated thrombin generation. The effect from fish oil alone is weak, but it is enhanced and may become clinically noticeable in patients taking antiplatelet therapy, and, to a lesser extent, in patients on factor Xa inhibitors and warfarin. In the absence of other anticoagulants, fish oil alone is not capable of producing a clinically significant coagulopathy that would induce or contribute to surgical bleeding. CONCLUSIONS: Patients who are taking fish oil without other anticoagulants do not have an increased risk of bleeding surgical complications. Because of the highly variable amounts of actual eicosapentaenoic acid and docosahexaenoic acid in commercially available supplements, thromboelastography with platelet mapping would allow a surgeon to know if a coagulopathic effect is present in a patient taking fish oil, especially if the patient was also taking other anticoagulants.

Case report of a giant colonic sigmoid diverticulum causing sigmoid volvulus.

INTRODUCTION: Giant colonic diverticulum is a rare complication of colonic diverticulosis that occurs when a single diverticulum enlarges to over 4cm in diameter. There have been fewer than 200 cases reported worldwide since it was first described in 1946. PRESENTATION OF CASE: The author presents a rare case of a giant colonic diverticulum that presented as a sigmoid volvulus. The patient underwent emergency surgery with resection of the diverticulum and reduction of the volvulus. DISCUSSION: Due to their propensity to cause complications and mechanical blockage from their large size, all authors recommend surgical resection of giant colonic diverticula. This has been documented to be safely done by diverticulectomy as was performed in this patient, but also by segmental colectomy, laparoscopic diverticulectomy, or laparoscopic colectomy. CONCLUSION: Giant colonic diverticulum is a rare entity that tends to cause many intra-abdominal complications, including volvulus. Surgical resection is recommended once identified.

Blunt traumatic infrarenal aortic intimal flap progressing to pseudoaneurysm over 3 months.

Blunt traumatic infrarenal aortic injuries are unusual, and the formation of a delayed pseudoaneurysm of the aorta is even more rare. In this report, a young woman developed a small intimal flap of the infrarenal aorta after a motor vehicle accident which progressed into a 3 cm pseudoaneurysm after 3 months. Operative repair was successful and the patient recovered. This case illustrates the importance of repeat imaging of small blunt aortic injuries since progression can occur.

Procalcitonin-guided antibiotic therapy for septic patients in the surgical intensive care unit.

In critically ill patients, elucidating those patients with the systemic inflammatory response syndrome (SIRS) from an infectious source (sepsis), versus those who have SIRS without infection, can be challenging since the clinical features are the same. Even with strict monitoring and testing, 39-98 % of patients with SIRS will never have bacteriological confirmation of an infection, and 6-17 % of patients with a documented infection will not show signs of SIRS. Due to this overlap, an extensive amount of research has been performed to investigate ways of determining and separating SIRS from infection, compared to SIRS due to trauma, surgical stress, or other non-infectious causes. This review article will discuss the recommended and peer-approved use of procalcitonin in septic patients in the intensive care unit and its use as a guide to antibiotic initiation and termination. The article will focus on the prospective randomized trials (Level 1 evidence) that have been conducted, and lesser levels of evidence will be referenced as needed to substantiate a conclusion. The literature documents multiple benefits of using procalcitonin as a guide to cost savings and appropriate termination of antibiotics by its use as a new objective marker of bacteremia that was previously not available. This article will show that antibiotics should be terminated when the procalcitonin level falls below 0.5 ng/mL.

Blunt cardiac trauma: a review of the current knowledge and management.

Blunt cardiac injuries are highly lethal. A review of the world's English literature on the topic reveals a lack of Level 1 Evidence and few cohesive guidelines for the management of these patients. An online database query was performed using the PubMed medical database. All relevant articles from the past 20 years were reviewed. Conclusions are presented with their corresponding Levels of Evidence.

Tissue expander-assisted ventral hernia repair for the skin-grafted damage control abdomen.

PURPOSE: To describe a novel technique using tissue expanders that allows skin coverage over large ventral hernia repairs after damage control laparotomy, including patients with stomas. METHODS: A retrospective study of a single author's experience with the technique. RESULTS: Tissue expanders were placed in the lateral abdominal wall skin adjacent to stomas and expanded over a short 6-week course. The expanders successfully stretched the skin to provide coverage over the large ventral hernia mesh repairs without infectious complications. CONCLUSIONS: The described technique is well tolerated by patients and very useful to provide skin coverage over large ventral hernia defects without infectious complications.

Intercostal artery aneurysmosis.

True intercostal artery aneurysms have been reported to occur in conjunction with neurofibromatosis, coarctation of the aorta, and Kawasaki disease. However, there has not been a previous report of a patient with intercostal artery aneurysmosis and no known or diagnosed associated condition. We describe the first such patient and review the literature.

Long-term functional and echocardiographic assessment after penetrating cardiac injury: 5-year follow-up results.

BACKGROUND: There is almost no data describing the long-term functional outcome of patients after penetrating cardiac injury. METHODS: A retrospective study at a Level I trauma center from 2000 to 2009. RESULTS: Sixty-three patients had penetrating cardiac injuries from 28 stabbings and 35 gunshots. Men comprised 89% (56) of the patients. Overall, there were 21 survivors (33%) and 42 died in the emergency room or perioperative period. The mean age did not significantly differ between survivors (36 years ± 12 years) compared with those who died (30 years ± 11 years; p=0.07). There was an increased chance of survival after being stabbed compared with being shot (17 patients vs. 4 patients; odds ratio=12; p=0.002). Thirteen (62%) had injuries to the right ventricle only. Three patients died during follow-up: one from lung cancer and two other patients died from myocardial infarctions, one 9 years later at the age of 45 years and the other 8 years later at the age of 55 years. The survivors had functional follow-up evaluations from 2 months to 114 months (median, 71; interquartile range, 34-92 months) and echocardiographic follow-up from 2 months to 107 months (median, 64; interquartile range, 31-84 months) after their injuries. Functionally, all patients were in NYHA class 1 status, except one patient in class II who was 54 years old and had a mild exertional limitation. The previously injured area could only be identified by echocardiogram in one patient who had a patch repair of a ventricular septal defect (VSD). The mean ejection fraction improved over time from a mean of 51% ± 8% in the immediate postoperative period to 60% ± 9% after a mean follow-up of 59 months (p=0.01). After surgery, 43% of patients had a mild to moderate pericardial effusion; however, the long-term follow-up studies showed that all these had resolved. Wall motion abnormalities occurred in 33% of patients in the immediate postoperative period and, again, all these resolved during long-term follow-up. CONCLUSIONS: Patients who survive penetrating cardiac injuries, without coronary arterial or valvular disruption, have an excellent long-term functional outcome with minimal subsequent cardiac morbidity related to the injury. Full physiologic recovery and normal cardiac function can be expected if the patient survives.