Postoperative pyoderma gangrenosum after gunshot wound: A case report.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis of unclear etiology that exhibits pathergy and can develop post-operatively in surgical incisions. To the best of our knowledge, this is the first case report of PG developing after a gunshot wound (GSW) injury or in a contaminated surgical wound. We further propose umbilical sparing as a key clinical finding differentiating the diagnosis of PG from more common infectious etiologies.

The utility of CT scan for the diagnostic evaluation of acute abdominal pain.

AbdCT for the evaluation of AAP in the ED in the US may be excessive and is potentially (although rarely) misleading and harmful. A selective policy of 'AbdUS first' combined with an observation unit and/or surgeon evaluation prior to AbdCT is preferred to a 'routine AbdCT' policy. Repeated AbdCTs for abdominal pain are not recommended because of cumulative radiation exposure. Standardized and complete history and physical examination, such as that originally designed for computer-aided diagnosis of AAP, along with select laboratory testing and higher utilization of AbdUS lessens the necessity of AbdCT. 'Routine AbdCT' is particularly not necessary for the evaluation of suspected appendicitis. 'Routine AbdCT' lowers the negative appendectomy rate but at the expense of exposure to radiation. Right lower quadrant US and selective use of observation prior to AbdCT for suspected appendicitis, particularly in children, adolescents, and young adults, are warranted. MRI should substitute for AbdCT for the evaluation of suspected appendicitis during pregnancy.

Outcomes associated with Interstim therapy for medically refractory fecal incontinence.

BACKGROUND: Fecal incontinence is a common, socially debilitating disorder. Initial management involves dietary manipulation with bulking agents or antidiarrheal medications and pelvic floor biofeedback. For patients failing these modalities, traditional surgical approaches are morbid and of variable efficacy. Sacral nerve neuromodulation (Interstim, sacral nerve stimulation) was approved in May 2011 for management of medically refractory fecal incontinence. This report summarizes our experience with this treatment modality. METHODS: A prospectively maintained database from a colorectal specialty practice was reviewed from December 2011 to June 2013. Patient demographics, incontinence etiology, and medical treatment regimens were reviewed. Outcomes for Interstim placement and surgical morbidity were reviewed. RESULTS: A total of 330 patients were evaluated in the clinic for fecal incontinence during the study period. A total of 33 patients (10%) were offered Interstim therapy. The mean age was 63 (39 to 91) years, and 91% (30 of 33) were female. The etiology of the incontinence was obstetric (81%), rectal prolapse (11%), neurogenic (5%), and iatrogenic (3%). The entire group failed either supplemental fiber or antidiarrheal medications and 73% (24 of 33) failed pelvic floor biofeedback. The mean number of bowel accidents/2-week bowel diary before implant was 19 (9 to 52). After phase I implant, 88% (29 of 33) experienced a successful test phase and proceeded to phase II permanent implant. The mean number of bowel accidents/2-week diary postimplant was 3 (0 to 12). A trend toward less severe episodes of incontinence postimplant was observed. There were no complications associated with either the phase I or phase II implant. There were no phase II failures although 1 patient underwent device explant 9 months after phase II implant for chronic pain. CONCLUSIONS: Sacral nerve neuromodulation (Interstim, sacral nerve stimulation) is an effective and efficacious tool for management of medically refractory fecal incontinence that offers a less morbid surgical approach to this problem. Interstim should be considered the first-line surgical approach for medically refractory fecal incontinence.

Outcomes of the fascial component separation technique with synthetic mesh reinforcement for repair of complex ventral incisional hernias in the morbidly obese.

INTRODUCTION: Complex ventral incisional hernias (VIH) in the morbidly obese remain a difficult management problem for the general surgeon. Multiple methods of repair with variable rates of success are described. The outcomes and techniques of a fascial component separation technique with synthetic mesh reinforcement in the morbidly obese are described. METHODS: Records of patients undergoing VIH repair between June 1996 and May 2007 who had a body mass index (BMI) greater than 30 kg/m(2) were reviewed from a prospectively maintained database. Patient demographics, BMI, hernia characteristics, perioperative and long-term complications, and long-term hernia recurrence rate were documented. RESULTS: A total of 90 patients (22 men and 68 women) meeting study criteria were identified. The mean age was 55 years (range 30-82 years). Mean BMI was 39.9 (range 30-68). Recurrent hernias were present in 43 patients (48%) Mean number of recurrences was 1.5 (range 1-5). A total of 42 patients (47%) had multiple fascial defects. Major perioperative morbidity was 8% and perioperative mortality was 1.1%. Postoperative wound infections occurred in 9 patients (10%). Hernia recurrence was observed in 5 patients (5.5%) with a mean follow-up of 50 months (range 1-132). CONCLUSIONS: Fascial component separation can be performed with acceptable perioperative morbidity and mortality. Rates of wound sepsis, mesh infection, mesh explantation and gastrointestinal mesh erosion are low. Operative time, hospital length of stay, and long-term VIH recurrence are also acceptably low. Fascial component separation is a viable technique for repair of complex VIH in the morbidly obese population.

Timing of intervention does not affect outcome in acute appendicitis in a large community practice.

BACKGROUND: Surgical management of acute appendicitis remains one of the most frequent problems faced by gastrointestinal surgeons. Traditional management has emphasized urgent surgical care. Recent literature suggests delayed surgery for acute appendicitis does not affect outcome. The outcomes of patients undergoing urgent and delayed appendectomy in a large community surgical practice are compared. METHODS: All patients undergoing appendectomy between August 2002 and May 2007 were reviewed retrospectively. The data were gathered from a large community surgical practice. Patient demographics, treatment times, and surgical, pathologic, and postsurgical outcomes were documented. RESULTS: A total of 1,198 patients underwent appendectomy (575 female/623 male). The mean time to surgical intervention was 7.1 hours (range, 1-24 h). The percentage of patients undergoing laparoscopy versus open versus surgical conversion was 63%, 33%, and 4%, respectively. The percentage of patients with acute appendicitis versus perforated acute appendicitis versus negative exploration was 77%, 14%, and 8.5%, respectively. Postoperative wound or intra-abdominal septic complications were observed in 5.3% and 2.6% of patients, respectively. There was no correlation between the duration of symptoms or time to surgical intervention and surgical approach, pathologic outcome, length of stay, or postoperative septic complications. CONCLUSIONS: Outcome variables documented in this study were independent of duration of symptoms or time to surgical intervention. This would suggest that short delays in surgical intervention for acute appendicitis are well tolerated. Outcome is related more clearly to the severity of the acute appendicitis at presentation.

The value of diverting loop ileostomy on the high-risk colon and rectal anastomosis.

INTRODUCTION: The need for diverting loop ileostomies to protect high-risk anastomoses has been questioned recently by several authors. This study was designed to evaluate the potential benefits and complications of diverting loop ileostomies in a high-risk anastomosis population. METHODS: Ninety-four consecutive patients undergoing diverting loop ileostomy were evaluated from a prospective database between 2003 and 2006. Criteria for diversion were: anastomosis less than 5 cm from the anal verge, previous pelvic radiation therapy, obstruction, and infection. Data regarding patient demographics, underlying pathology, anastomotic problems, and ileostomy-related problems were gathered. RESULTS: Indications for surgery were malignancy (n = 40), ulcerative colitis (n = 37), acute diverticulitis (n = 12), perirectal fistulas (n = 3), and familial polyposis (n = 2). There were 5 anastomotic complications. One required permanent stoma and 4 required delay in diverting ileostomy closure but no other intervention. Ileostomy-related problems were limited to minor stoma and pouch complaints requiring stoma nurse evaluation (n = 23), dehydration requiring outpatient (n = 8) or inpatient (n = 4) intravenous fluids, stricture at stoma closure site (n = 2), and bleeding at stoma closure site (n = 1). Four stoma site hernias (4.3%) have been identified to date. CONCLUSION: The use of diverting loop ileostomy in patients undergoing colon and rectal surgery with high-risk anastomoses is beneficial. Their selected use has resulted in a 1% anastomotic loss rate with an acceptably low rate of complications related to the ileostomy.

Martius flap: an adjunct for repair of complex, low rectovaginal fistula.

BACKGROUND: Complex, rectovaginal fistula (RVF) are uncommon but difficult therapeutic problems. Local repair and flap advancement techniques have a high incidence of recurrence with poor functional outcomes. Transperineal repair with anal sphincter reconstruction, when indicated, and placement of a Martius flap (bulbocavernosus pedicled transplant) result in improved rates of repair and better functional outcomes. METHODS: A consecutive series of patients were retrospectively reviewed from a prospective database between 2002 and 2006. Data were gathered from 2 colon- and rectal-specialty practices. Patient demographics and operative and functional outcomes were documented. RESULTS: Sixteen patients with a mean age of 39.5 years (17-62) were treated. Etiology of the fistula was obstetric (9), cryptoglandular (5), and Crohn's disease (2). They had undergone a mean of 1.5 (0-4) prior repairs, and 6 had a preexisting diverting stoma before repair. Preoperatively, anal sphincter disruption was identified in 11 patients, and fecal incontinence was identified in 5 patients all with anal sphincter disruption. Dyspareunia was identified in 1 of 13 sexually active patients preoperatively. At a mean follow-up of 75 weeks (24-190), 1 recurrent fistula was identified (6.2%). Stomas were reversed in all patients. Two patients complained of fecal incontinence postoperatively. Five patients had dyspareunia postoperatively (5/16, 31%). One patient had a labial wound complication requiring local wound care. CONCLUSION: Selected complex RVF can be reliably repaired with good functional outcomes using the Martius flap with anal sphincter reconstruction. Persistent or recurrent fecal incontinence and dyspareunia are common sequela of the underlying perineal injury and repair. No acute or delayed morbidity related to the Martius flap was identified.

Outcomes of a laparoscopic approach for total abdominal colectomy and proctocolectomy.

BACKGROUND: The role of laparoscopy for total abdominal colectomy (TAC) and total proctocolectomy (TPC) has been controversial given its technical difficulty, high conversion rate, and complication rate. Recent studies have documented its efficacy for experienced laparoscopic surgeons. The outcomes of a prospective series of patients undergoing TAC and TPC are presented. METHODS: A consecutive series of patients undergoing TAC or TPC were identified from prospectively collected data during 2002 to 2005. The database reflects a single colon and rectal surgical specialty practice. Patient characteristics, surgical parameters, and patient outcomes were documented. RESULTS: From a total of 51 patients, 19 underwent TAC and 32 underwent TPC. There were 26 women and 35 men. The mean patient age was 40 years (range, 17-74 y). The mean body mass index was 25 (range, 19-38). Twelve patients underwent surgery for colonic inertia, 2 for familial adenomatous polyposis, and 37 for chronic ulcerative colitis. Of the ulcerative colitis patients, 8 patients had toxic colitis, 4 had dysplasia, and 25 had medically refractory disease. The overall mean surgical time was 163 minutes (range, 85-227 min): the mean surgical time for TAC was 131 minutes (range, 85-189 min) and for TPC was 197 minutes (range, 131-227 min). The overall mean blood loss was 200 mL (range, 75-500 mL). The mean length of stay was 4.8 days (range, 2-16 d). Open conversion was required in 5 patients: 3 with toxic colitis (38%), and 2 during elective colectomy (4.8%). Ten complications occurred (19.7%) with no mortality. CONCLUSIONS: A laparoscopic approach to TAC and TPC is efficacious and safe. It is a viable alternative to open surgery for surgeons experienced with the laparoscopic approach to colectomy. Patients with toxic colitis may undergo a laparoscopic approach but will have a higher open conversion rate.

Laparoscopic splenectomy for treatment of splenomegaly.

BACKGROUND: Laparoscopic splenectomy presents an advantage over open splenectomy, resulting in shorter hospital stay, decreased blood loss, and fewer operative and postoperative complications. Splenomegaly has long been considered a contraindication for laparoscopic splenectomy; however, in the hands of an experienced surgeon, this technique can be effectively applied to the treatment of splenomegaly. METHODS: Records for patients undergoing laparoscopic splenectomy for splenomegaly between 2000 and 2003, performed by a single surgeon in three community-based hospitals, were reviewed and demographic, operative, and postoperative data compiled. Preoperative diagnoses included B cell lymphoma, hemolytic anemia, and chronic lymphocytic leukemia. RESULTS: Seven patients underwent laparoscopic and hand-assisted laparoscopic splenectomy for splenomegaly during this time period. Splenic weights ranged from 410 to 3,100 g, and average operative time was 86.6 minutes. Estimated blood loss ranged from 50 to 350 ml; average hospital stay was 4.4 days. Two postoperative complications, ie, postoperative bleeding and superficial wound breakdown, were noted. CONCLUSIONS: Laparoscopic and hand-assisted laparoscopic splenectomy are effective methods for treatment of splenomegaly.