Conservative management of severe caustic injuries during acute phase leads to superior long-term nutritional and quality of life (QoL) outcome.

PURPOSE: Best clinical management of severe caustic injury is still a subject of debate. Most surgical teams consider severe caustic injury as an indication for emergency surgery. But, under certain circumstances, conservative management is feasible, avoids the need for gastrectomy, and has a low mortality rate. Postponed reconstructive surgery is usually performed several months after caustic ingestion to restore intestinal continuity or to treat stricture sequelae. This study aimed to investigate long-term nutritional and quality of life (QoL) outcomes after reconstructive surgery for high-grade esophageal and gastric caustic injury. METHODS: Twenty-one patients were assessed for biological and nutritional parameters, physical findings, and quality of life surveys at least 25 months after reconstructive surgery among patients who have required emergency surgery (n = 10) and patients who did not undergo emergency surgery (n = 11). RESULTS: After median follow-up of 74 months (after caustic ingestion) and 67 months (after reconstructive surgery), patients who avoided emergency surgery experienced faster oral diet resumption (49 vs. 157 days, p = 0.004), less weight loss (0.3 vs. 20 kg, p = 0.002), greater body fat percentage (22 vs. 18 %, p = 0.046), better nutritional and physical status (SF12 PCS 51 vs. 43, p = 0.036), and less trouble eating (EORTC QLQ-OG 25 31 vs. 56, p = 0.01). CONCLUSIONS: Our study is the first to evaluate long-term nutritional and QoL outcomes, following severe caustic injury. It demonstrates better long-term nutritional outcomes and QoL in patients suitable for initial conservative management. These results support full functional recuperation of spared organs, even severely burned. In the absence of clinical or biological signs necessitating immediate surgery, conservative management should be advocated.

Outcome in porcine acellular dermal matrix reinforcement of infected abdominal wall defects: a prospective study.

PURPOSE: Management of infected abdominal wall defects is a subject of debate, and the use of prosthetic mesh repair is not recommended due to the dramatic rate of mesh infection. The aim of this prospective study was to determine the recurrence rate and long-term outcomes of repairing infected abdominal wall defects using the Strattice porcine acellular dermal matrix reinforcement through a single-stage surgical approach. METHODS: From August 2010 to May 2012, consecutive patients treated for infected abdominal wall defects using Strattice, a biologic prosthesis, were enrolled. All data were collected prospectively and all patients were followed for physical examination and CT scan evaluation. The primary outcome measure was the recurrence rate. RESULTS: Eighteen patients were enrolled and 14 were evaluable. Of these, eight patients had mesh infections and six had enterocutaneous fistulas. Median follow-up was 13 months (range, 3-22) and median length of hospitalization was 13 days (range, 4-56). The Strattice was placed in the intraperitoneal underlay position in 12 patients, and in the retro-rectus position for two. Post-operative complications included skin dehiscence (n = 3), wound infection (n = 2), skin necrosis (n = 1), and seroma (n = 2). At the end of follow-up, six patients (43 %) experienced abdominal wall defect recurrence. CONCLUSIONS: The utility of biologic prostheses to repair infected abdominal wall defects is controversial; however, currently, they remain the only alternative to a two-staged surgery. Prospective, randomized studies in larger populations of patients are necessary to fully determine the usefulness of biologic prostheses in this setting.

Efficacy of sacral nerve stimulation for poor functional results of J-pouch ileoanal anastomosis.

PURPOSE: Ileoanal anastomoses (J-pouches) are an alternative to permanent ostomy. The functional outcomes associated with the use of J-pouches are usually good, but continence disorders persist in a significant number of cases and have a negative impact on quality of life. The aim of this study was to assess the efficacy of sacral nerve stimulation (SNS) for poor functional results after J-pouch ileoanal anastomosis. METHODS: Patients suffering from severe fecal incontinence (FI) following coloproctectomy underwent a staged implant SNS procedure. Demographic data and functional results for FI episodes, urgencies per week, frequency of stools, ability to defer defecation, and Wexner scores were obtained at specified intervals. Patients also completed quality-of-life assessments. RESULTS: Four female patients were included in this analysis. All 4 experienced active and passive FI at baseline and subsequently underwent test stimulation with a 75 % success rate. Three received definitive implants. These 3 patients experienced improvement in functional outcomes at 1, 3, and 6 month assessments. Improvements in quality of life were also noted. CONCLUSIONS: Our preliminary study suggests that SNS is effective for the treatment of poor functional results following J-pouch ileoanal anastomosis; however, larger studies with long-term follow-up are needed for confirmation of our findings.

Gallium nitrate induces fibrinogen flocculation: an explanation for its hemostatic effect?

A novel hemostatic effect of gallium nitrate has recently been discovered. Our aim was to perform a preliminary investigation into its mode of action. Thromboelastography® showed no effect on coagulation but pointed instead to changes in fibrinogen concentration. We measured functional fibrinogen in whole blood after addition of gallium nitrate and nitric acid. We found that gallium nitrate induces fibrinogen precipitation in whole blood to a significantly higher degree than solutions of nitric acid alone. This precipitate is not primarily pH driven, and appears to occur via flocculation. This behavior is in line with the generally observed ability of metals to induce fibrinogen precipitation. Further investigation is required into this novel phenomenon.