Intra-abdominal hypertension and hypoxic respiratory failure together predict adverse outcome - A sub-analysis of a prospective cohort.

PURPOSE: To assess whether the combination of intra-abdominal hypertension (IAH, intra-abdominal pressure ≥ 12 mmHg) and hypoxic respiratory failure (HRF, PaO2/FiO2 ratio < 300 mmHg) in patients receiving invasive ventilation is an independent risk factor for 90- and 28-day mortality as well as ICU- and ventilation-free days. METHODS: Mechanically ventilated patients who had blood gas analyses performed and intra-abdominal pressure measured, were included from a prospective cohort. Subgroups were defined by the absence (Group 1) or the presence of either IAH (Group 2) or HRF (Group 3) or both (Group 4). Mixed-effects regression analysis was performed. RESULTS: Ninety-day mortality increased from 16% (Group 1, n = 50) to 30% (Group 2, n = 20) and 27% (Group 3, n = 100) to 49% (Group 4, n = 142), log-rank test p < 0.001. The combination of IAH and HRF was associated with increased 90- and 28-day mortality as well as with fewer ICU- and ventilation-free days. The association with 90-day mortality was no longer present after adjustment for independent variables. However, the association with 28-day mortality, ICU- and ventilation-free days persisted after adjusting for independent variables. CONCLUSIONS: In our sub-analysis, the combination of IAH and HRF was not independently associated with 90-day mortality but independently increased the odds of 28-day mortality, and reduced the number of ICU- and ventilation-free days.

Laparoscopic Common Bile Duct Exploration for Choledocholithiasis: Analysis of Practice Patterns of Intermountain HealthCare.

BACKGROUND: The ideal management of common bile duct (CBD) stones remains controversial, whether with single-stage management using laparoscopic CBD exploration (LCBDE) during laparoscopic cholecystectomy, or with 2-stage management using preoperative or postoperative ERCP. We wished to elucidate the practice patterns within our health system, which includes both large urban referral centers and small rural critical access hospitals. STUDY DESIGN: We conducted a retrospective data analysis from our 22-hospital, not-for-profit, integrated healthcare system. All patients with a diagnosis of choledocholithiasis who underwent laparoscopic cholecystectomy (LC) and either ERCP or LCBDE for duct clearance between 2008 and 2013 were included. Demographic data, along with disease-specific characteristics and outcomes, were collected and compared. RESULTS: During the study period, 37,301 patients underwent LC. Of these, 1,961 (5.3%) met inclusion criteria. Single-stage management with LC+LCBDE was performed in 28% of patients, and the remaining 72% underwent 2-stage management with ERCP (73% postoperative ERCP, 27% preoperative). Mean total number of procedures was lowest in the LC+LCBDE group vs the post-cholecystectomy ERCP group vs the preoperative ERCP group (mean 1.4 vs 2.1 vs 2.3; p < 0.05). Hospital charges were also lower in the LC+LCBDE group vs post-cholecystectomy ERCP vs preoperative ERCP groups ($9,000 vs $10,800 vs $14,200; p < 0.05). Single-stage vs two-stage management varied greatly between hospitals (from 0% to 93%). CONCLUSIONS: Single-stage management of CBD stones resulted in the fewest procedures and lower hospital charges without an increase in complications. Single-stage management (LC+LCBDE) of CBD stones is underused and can offer better value in today's cost-constrained environment.

Pyloroplasty Offers Relief of Postfundoplication Gastroparesis in Patients Who Improved After Botulinum Toxin Injection.

BACKGROUND: Endoscopic intrapyloric Botox (onabotulinumtoxin A; Allergan Pharmaceuticals) injections can improve postfundoplication gastroparesis, but responses are not durable. Surgical pyloroplasty may relieve gastroparetic symptoms, but patient selection criteria are poorly defined. We hypothesize that pyloroplasty provides durable improvement in patients whose symptoms improved after Botox injection. STUDY DESIGN: A retrospective chart review was performed of patients with postfundoplication gastroparesis who improved after Botox injection and then underwent pyloroplasty. Gastric emptying studies (GES), Gastroparesis Cardinal Symptom Index (GCSI) score, symptoms, and outcomes were reviewed. RESULTS: Ten patients received Heineke-Mikulicz pyloroplasty after reporting improvement with Botox injection. The mean operative time was 114 minutes (range 55-234 minutes). Three of 10 patients required conversion to open surgery, and the median length of stay was 3 days. Gastroparesis symptom improvement occurred in 9 of 10 patients. Postoperative GES normalized in 5/5 patients (median 205 decreased to 70 min, P < .05). Median preoperative GCSI was 3.67, improved to 2.22 at 1 month postsurgery (P = .010) and to 2.11 on most recent follow-up (P = .015). Median duration of follow-up was 34 months (range 1-101 months). CONCLUSION: Heineke-Mikulicz pyloroplasty can improve symptoms and gastric emptying times in patients with postfundoplication gastroparesis. Improvement with intrapyloric Botox injection may select candidates for pyloroplasty.

Predictors of Monomicrobial Necrotizing Soft Tissue Infections.

BACKGROUND: Broad-spectrum antibiotic therapy is critical in the management of necrotizing soft tissue infections (NSTI) in the emergency setting. Clindamycin often is included empirically to cover monomicrobial gram-positive pathogens but probably is of little value for polymicrobial infections and is associated with significant side effects, including the induction of Clostridium difficile colitis. However, there have been no studies predicting monomicrobial infections prior to obtaining cultures. The purpose of this study was to identify independent predictors of monomicrobial NSTI where the use of clindamycin would be most beneficial. We hypothesized that monomicrobial infections are characterized by involvement of the upper extremities and fewer co-morbid diseases. METHODS: We reviewed all cases of potential NSTI occurring between 1996 and 2013 in a single tertiary-care center. The infection was diagnosed by the finding of rapidly progressing necrotic fascia during debridement with positive cultures of tissue. Univariable analysis was performed using the Student t-, Wilcoxon rank sum, χ2, and Fisher exact tests as appropriate. Multivariable logistic regression was used to identify independent variables associated with outcomes. RESULTS: A group of 151 patients with confirmed NSTI with complete data was used. Of the monomicrobial infections, 61.8% were caused by Group A streptococci, 20.1% by Staphylococcus aureus, and 12.7% by Escherichia coli. Of the polymicrobial infections, E. coli was involved 13.7% of the time, followed by Candida spp. at 12.9%, and Bacteroides fragilis at 11.3%. On univariable analysis, immunosuppression, upper extremity infection, and elevated serum sodium concentration were associated with monomicrobial infection, whereas morbid obesity and a perineal infection site were associated with polymicrobial infection. On multivariable analysis, the strongest predictor of monomicrobial infection was immunosuppression (odds ratio [OR] 7.0; 95% confidence interval [CI] 2.2-22.3) followed by initial serum sodium concentration (OR 1.1; 95% CI 1.0-1.2). Morbid obesity (OR 0.1; 95% CI 0.0-0.5) and perineal infection (OR 0.3; 95% CI 0.1-0.8) were independently associated with polymicrobial infection. CONCLUSION: We identified independent risk factors that may be helpful in differentiating monomicrobial from polymicrobial NSTI. We suggest empiric clindamycin coverage be limited to patients who are immunosuppressed, have an elevated serum sodium concentration, or have upper extremity involvement and be avoided in obese patients or those with perineal disease.

Surgical management of lower urinary mesh perforation after mid-urethral polypropylene mesh sling: mesh excision, urinary tract reconstruction and concomitant pubovaginal sling with autologous rectus fascia.

INTRODUCTION AND HYPOTHESIS: We present our management of lower urinary tract (LUT) mesh perforation after mid-urethral polypropylene mesh sling using a novel combination of surgical techniques including total or near total mesh excision, urinary tract reconstruction, and concomitant pubovaginal sling with autologous rectus fascia in a single operation. METHODS: We retrospectively reviewed the medical records of 189 patients undergoing transvaginal removal of polypropylene mesh from the lower urinary tract or vagina. The focus of this study is 21 patients with LUT mesh perforation after mid-urethral polypropylene mesh sling. We excluded patients with LUT mesh perforation from prolapse kits (n = 4) or sutures (n = 11), or mesh that was removed because of isolated vaginal wall exposure without concomitant LUT perforation (n = 164). RESULTS: Twenty-one patients underwent surgical removal of mesh through a transvaginal approach or combined transvaginal/abdominal approaches. The location of the perforation was the urethra in 14 and the bladder in 7. The mean follow-up was 22 months. There were no major intraoperative complications. All patients had complete resolution of the mesh complication and the primary symptom. Of the patients with urethral perforation, continence was achieved in 10 out of 14 (71.5 %). Of the patients with bladder perforation, continence was achieved in all 7. CONCLUSIONS: Total or near total removal of lower urinary tract (LUT) mesh perforation after mid-urethral polypropylene mesh sling can completely resolve LUT mesh perforation in a single operation. A concomitant pubovaginal sling can be safely performed in efforts to treat existing SUI or avoid future surgery for SUI.