Open abdomen and VAC® in severe diffuse peritonitis.

BACKGROUND: Currently, the open abdomen technique is the widely recognised method for treatment of life-threatening trauma, intra-abdominal sepsis, abdominal compartment syndrome and wound dehiscence. The techniques for temporary closure using negative pressure have gained increasing popularity. Although negative pressure wound therapy has been proved as an effective method in trauma, the results in diffuse peritonitis are contradictory. METHODS: Overall, 108 patients with diffuse peritonitis and open abdomen were prospectively enrolled from January 2006 to December 2013--69 treated with mesh-foil laparostomy without negative pressure and 49 with vacuum-assisted closure (VAC(®)) The primary endpoints were the rate of primary fascial closure and mortality. The secondary outcomes were the rate of complications--enteroatmospheric fistulas, intra-abdominal abscesses, wound infection and necrotising fasciitis, intensive care unit (ICU) and overall hospital stay. RESULTS: VAC was associated with higher overall (73% vs 53%) and late primary fascial closure rates (31% vs 7%), lower rates of necrotising fasciitis (2% vs 15%, p=0.012), intra-abdominal abscesses (10% vs 20%), enteroatmospheric fistulas (8% vs 19%), overall mortality (31% vs 53%, p<0.05), shorter ICU (6.1 vs 10.6 days, p=0.002) and hospital stay (15.1 vs 25.9 days, p=0.000). CONCLUSIONS: The results clearly suggest the obvious advantage of VAC in comparison to the temporary abdominal closure without negative pressure in the cases with severe diffuse peritonitis. However, to a large extent, our results might be attributed to the combination of VAC with dynamic fascial closure.

Mesenteric cystic lymphangioma: unusual cause of intra-abdominal catastrophe in an adult.

Mesenteric cystic lymphangiomas (MCLs) are rare benign cystic tumours of unknown aetiology, most often seen in paediatric patients. The clinical presentation is diverse, ranging from an incidentally discovered abdominal cyst to symptoms of acute abdomen. A 20-year-old male presented with generalised abdominal pain, nausea and vomiting of several hours duration following heavy lifting. Emergency laparotomy revealed a 15 x 10 x 8-cm pedicled cystic mass of the mid-ileal mesentery, causing a volvulus. The cyst and a 20-cm gangrenous intestinal segment were resected with anastomosis. The postoperative course was uncomplicated. MCLs should be included in the differential diagnosis of cystic intra-abdominal lesions. Even when asymptomatic and discovered incidentally, they must be treated surgically because of the potential to grow, invade vital structures and develop life-threatening complications.

Gastrointestinal "crosses": an indication for surgery.

BACKGROUND: We present our experience with a unique type of foreign body that was specifically designed to arrest in its passage and cause perforation of the gastrointestinal tract. STUDY: Between 1994 and 1999, nine male prisoners from the same jail presented after ingestion of "crosses." A cross is constructed from the two halves of a standard paperclip that are tied together with a rubber band. The resulting construction is elastic: the two branches can be pulled to lie parallel, but they assume their original position once released. The cross is wrapped into paper with its branches parallel and ingested. After release from the wrapper, it "opens" and causes bowel perforations. RESULTS: All patients underwent emergency surgery for foreign body removal and treatment of peritonitis. A total of 19 crosses were removed from the patients. Six (32%) were found in the stomach; five, in the duodenum (28%); three, in the jejunum and ileum (16%); and one, in the pylorus and colon. There was no morbidity or mortality. CONCLUSIONS: Foreign bodies of this type never pass distally. The ultimate key to success in the management of patients who have ingested crosses is emergency surgical intervention.

Recurrent idiopathic perforations of the small intestine.

BACKGROUND/AIMS: Idiopathic perforation of the small intestine is extremely rare. The definition depends on the absence of any detectable pathology that could be responsible for the perforation. This study was undertaken to outline the criteria for determination of the condition. METHODS: Case report and review of the literature. RESULTS: A 50-year-old male patient underwent surgery including laparostomy and planned reexplorations for multiple recurrent small intestinal perforations of unknown origin; the patient made an uneventful recovery. Extensive investigations were carried out to search for any pathology that could explain the occurrence of perforations, but yielded no results. CONCLUSIONS: Further studies will possibly give more information concerning idiopathic perforation of the small intestine, provided that judicious criteria for its determination are applied.

Subcutaneous splenosis: a clue to diagnosis of thoracic splenosis.

We describe a unique case of combined thoracic and subcutaneous splenosis.

Surgery for deeply located hydatid cysts of the liver: a simple alternative.

Gaining access to deeply located hydatid cysts of the liver using conventional surgical techniques may be accompanied by significant intra- and postoperative complications. In addition, obliteration of the cyst cavity is still a matter of controversy. We developed a novel method for easy access to deep hydatid cysts using a water jet dissector (Parenchimotom 01, TOSA, Pleven, Bulgaria). At pressure of 20 Bar using a 0.2 mm nozzle, a corridor is created through the liver parenchyma overlying the cyst; vessels and biliary duct are thus clearly displayed as linear structures traversing the corridor and are ligated and divided under direct visual control. The fibrous capsule of the cyst is spared by the jet. Following endocystectomy performed in the ordinary manner, the cyst cavity is filled with gelatin sponge; a passive tube drain is placed in contact with the liver incision. In allowing for a selective dissection of the liver parenchyma, the jet makes safe access to deeply located hydatid cysts possible. On the other hand, the gelatin sponge induces good fibroblast response and assists in rapid and effective obliteration of the residual cavity. This novel technique works well in our hands but more extensive studies are necessary before its final acceptance.