Vacuum and mesh-mediated fascial traction for primary closure of the open abdomen in critically ill surgical patients.

BACKGROUND: Several temporary abdominal closure techniques have been used in the management of open abdomen. Failure to achieve delayed primary fascial closure results in a large ventral hernia. This retrospective analysis evaluated whether the use of vacuum-assisted closure and mesh-mediated fascial traction (VACM) as temporary abdominal closure improved the delayed primary fascial closure rate compared with non-traction methods. METHODS: Patients treated with an open abdomen between 2004 and 2010 were analysed. RESULTS: Among 50 patients treated with VACM and 54 using non-traction techniques (control group), the delayed primary fascial closure rate was 78 and 44 per cent respectively (P < 0·001); rates among those who survived to abdominal closure were 93 and 59 per cent respectively. Independent predictors of delayed primary fascial closure in multivariable logistic regression analysis were the use of VACM (odds ratio (OR) 4·43, 95 per cent confidence interval 1·64 to 11·99) and diagnosis other than peritonitis, severe acute pancreatitis or ruptured abdominal aortic aneurysm (OR 3·45, 1·07 to 11·04), which represented the main diagnoses. Prophylactic open abdomen was used to inhibit the development of intra-abdominal hypertension more frequently in the VACM group (28 versus 7 per cent; P = 0·008). Twelve per cent of patients in the VACM group developed an enteroatmospheric fistula compared with 19 per cent of control patients. Among survivors, three of 31 treated with VACM and 17 of 36 controls were left with a planned ventral hernia (P = 0·001). CONCLUSION: The indication for open abdomen contributed to the probability of delayed primary fascial closure. VACM resulted in a higher fascial closure rate and lower planned hernia rate than methods that did not provide fascial traction.

Components separation technique is feasible for assisting delayed primary fascial closure of open abdomen.

BACKGROUND AND AIMS: The goal after open abdomen treatment is to reach primary fascial closure. Modern negative pressure wound therapy systems are sometimes inefficient for this purpose. This retrospective chart analysis describes the use of the 'components separation' method in facilitating primary fascial closure after open abdomen. MATERIAL AND METHODS: A total of 16 consecutive critically ill surgical patients treated with components separation during open abdomen management were analyzed. No patients were excluded. RESULTS: Primary fascial closure was achieved in 75% (12/16). Components separation was performed during ongoing open abdomen treatment in 7 patients and at the time of delayed primary fascial closure in 9 patients. Of the former, 3/7 (43%) patients reached primary fascial closure, whereas all 9 patients in the latter group had successful fascial closure without major complications (p = 0.019). CONCLUSION: Components separation is a useful method in contributing to successful primary fascial closure in patients treated for open abdomen. Best results were obtained when components separation was performed simultaneously with primary fascial closure at the end of the open abdomen treatment.

Reconstruction of an abnormal hepatic vein in a donor liver: a case report.

In the era of worldwide organ shortage for liver transplantation, every effort must be made to use all potentially available livers. In this case report, we present a liver graft with abnormal left hepatic vein draining directly to the right atrium of the donor heart, which was discovered during back table preparation of a liver graft. The vein was reconstructed and the subsequent liver transplantation was successful. Five years after the transplantation, no signs of complications have emerged.

Ureteral repair with titanium staples: comparison with suture closure.

OBJECTIVES: Vascular closure staple (VCS) clips made of titanium were initially developed for microvascular anastomoses with little knowledge of their effectiveness in larger tubular tissue structures. This study compares VCS clips and sutures in the closure of longitudinal ureterotomy incisions. METHODS: In 9 pigs, 1-cm-long anterior, longitudinal ureterotomy incisions were randomly assigned to closure with either 4-0 interrupted polyglactin sutures or VCS clips. RESULTS: Clip closure was significantly faster (74+/-28 versus 534+/-182 seconds). All 18 ureters were patent and without signs of leakage, calculus formation, or stenoses after 3 months. Clip closure resulted in slightly but not statistically significantly less narrowing of the duct lumen, but there was no difference in wall thickness at the repair site. At histologic examination, all 18 incisions healed without signs of acute inflammation or marked fibrosis. CONCLUSIONS: Ureterotomy closure with VCS clips results in wound healing that is as effective as suture closure, with a comparable degree of narrowing. The time required for clip closure is only about 1/7 that required for suture closure.

Severe acute pancreatitis: prognostic factors in 270 consecutive patients.

Acute pancreatitis (AP) is a common abdominal disorder with severity varying from mild to fatal disease. Predicting a patient's outcome remains problematic. The aim of this study was to analyze a large consecutive series of patients with severe AP and to identify prognostic factors for hospital mortality. Between 1989 and 1997, a consecutive series of 270 patients with severe AP were included in the study. All patients fulfilled the criteria of Atlanta classification for severe AP. Retrospectively and prospectively collected data included age, gender, etiology, number of previous episodes of pancreatitis, medication history, type of admission, body-mass index (BMI), respiratory failure, renal failure, need for pressor support, and abdominal surgery performed during hospitalization. The overall mortality rate was 24.4%. In univariate survival analysis advanced age, history of continuous medication, patient transferred from other hospital, high BMI, respiratory or renal failure, need for pressor support, and need for abdominal surgery were significant prognostic factors for hospital mortality. In a multivariate stepwise logistic regression analysis, the need of pressor support, renal failure requiring dialysis, advanced age, history of continuous medication and need for abdominal surgery were identified as independent prognostic factors for mortality. A logistic regression analysis of variables available on admission (the first seven above mentioned variables) showed that transferral admission, advanced age, and history of continuous medication were independent prognostic factors for mortality. In patients with severe AP, advanced age, history of continuous medication, and need for dialysis, mechanical ventilator support, and pressor support predict fatal outcome and thus should be taken into account in clinical evaluation.

Prognosis after lymph node recurrence in papillary thyroid carcinoma depends on age.

Papillary thyroid carcinoma (PTC) is a malignancy that has good prognosis especially among patients up to 45 years of age; about half of the patients are female and of childbearing age. Lymph node recurrence (LNR) occurs in 10%-14% of patients but is considered to be associated with relatively good prognosis. The purpose of this study was to estimate the association between patient age at primary operation, and the behavior of the disease after LNR. Between 1967 and 1994, 495 patients underwent surgery for primary PTC at the Department of Surgery, Helsinki University Central Hospital. There were 391 (79.0%) women and 104 (21.0%) men with a mean age of 44.5 years (range, 10.8-85.4 years). Fifty-eight patients in whom LNR was the first clinical sign of persistent disease after complete clinical response to primary treatment were included in this series. At the time of primary operation, 37 (64.3%) of the 58 patients who developed LNR were younger than 45 years of age and 21 patients were older. The mean times to LNR in these groups were 42.0 months (range, 3.0-194.5 months) and 49.0 months (range, 3.6-209.0 months) respectively. Carcinoma-specific 5-year survival after LNR was 100% (95% confidence interval [CI] 88.8%-100.0%) in patients ages up to 45 years and 61.1% (40.5%-82.8%) in older patients; 10-year survival rates were 100%, and 41.3% (p < 0.0001), respectively. Relative survival at 10 years was 98.6% for patients ages up to 45 years and 42.6% for older patients (p = 0.0014). Using the Cox model it was shown that development of LNR after primary treatment has an independent highly significant negative effect on survival (p < 0.001) in patients over 45 years of age. Prognosis of PTC even after LNR on patients ages up to 45 years at the time of the primary operation is almost parallel to the normal reference population, but in patients over 45 years of age the prognosis is relatively poor.

Obstetrics and the general surgeon.

From a small Pacific island country of Tuvalu, an analysis of 132 obstetric and gynecologic patients operated upon by one general surgeon during a 20.5 month period from 1988 to 1989 was performed. The operations comprised 50 percent of all surgical procedures and were associated with complicated pregnancy and delivery in 48 percent of the patients, birth control and infertility in 34 percent and gynecologic neoplasms, infections and bleeding ex utero in 18 percent. There was no mortality and 11 patients had lesser complications. Of the 38 cesarean sections, 76 percent were emergency operations. The main indications for cesarean section were dystocia in 55 percent of the patients and previous cesarean section in 24 percent. There was no maternal mortality. The complication rate was 13 percent and included two neonatal deaths. The cesarean birth rate during the study period was 7.6 percent, a nearly fivefold increase from the previous 9.5 years. With other factors remaining unchanged, the increase in cesarean birth rate corresponded to a decrease in neonatal death rate from 35.7 to 15.7 per 1,000 live-born infants. It is concluded that a considerable share of work of a general surgeon in developing countries consists of obstetric and gynecologic procedures. This should be taken into consideration when training and recruiting surgeons for that kind of work. A general surgeon with obstetric experience can perform cesarean section with an acceptable morbidity rate and should not hesitate to do it whenever labor does not progress as expected. The decision to operate can be based on physical examination with close cooperation with the midwife. In developing countries, increasing cesarean birth rates alone seem to reduce considerably the neonatal death rates.

Where there is no anaesthetist....

In an unselected series of 254 operations representing a wide range of surgical, obstetric and gynaecological procedures carried out on the small Pacific island of Tuvalu, the majority (85 per cent) involved the lower half of the body. In all cases but one anaesthesia was administered by a non-specialist. In operations below the level of the diaphragm epidural anaesthesia was usually used with a success rate of 96 per cent. In the upper half of the body ketamine was used where local or regional block was insufficient. Only one operation was performed under general inhalation anaesthesia. The overall postoperative mortality rate was 0.4 per cent and the morbidity rate was 13 per cent. Only two minor complications were attributed to the anaesthetic method used. In situations where anaesthetists are not available, epidural and ketamine anaesthesia in the hands of non-specialists are safe and practical options to general inhalation anaesthesia and are appropriate for most surgical procedures.

Intravesical foreign body after inguinal herniorrhaphy. Case report.

A 36-year-old male teacher living on the Pacific Island of Tuvalu presented with a surgical gauze swab that had been left behind after an inguinal hernia operation. It had migrated into the urinary bladder where it had remained for 15 months.

Hepatic stab wound with retrohepatic vena cava and hepatic artery injuries.

A case of a hepatic stab wound with concomitant retrohepatic vena cava and hepatic artery injuries is presented. A direct non-shunting technique of caval repair was used. The management options of retrohepatic vena caval injuries, and the effect of hepatic artery inflow on liver regeneration after major hepatic resection are discussed.

Medical challenges of internal conflicts.

The most prevalent menace since the end of the cold war is the occurrence of civil wars and local and regional conflicts. The term "low intensity conflict" describes the new threat environment and covers a multitude of phenomena, such as civil wars, guerrilla warfare, terrorism and counterinsurgency operations occurring between routine, peaceful inter- or intrastate competition, and a sustained conventional conflict. There is a great challenge to alert the physicians in general, and the surgical community of the world in particular, to the new threat environment and the medical challenges involved in treating casualties of low intensity conflicts. Specifically, a new international body of surgeons might be required to coordinate the recruitment, training, and creditation for surgeons with special expertise in the management of victims of such conflicts and to facilitate research and general knowledge of the medical challenges of modern conflicts.

Surgery in Tuvalu: a 10-year review.

A total of 1084 surgical procedures was performed during the first 10 years of independence in the small Pacific island nation of Tuvalu. Visiting surgical teams performed 29% of these. Obstetrical and gynaecological operations, eye and abdominal operations counted for more than half of the total number of operations; of the individual operations, cataract extraction, tubal ligation and appendicectomy were the most common. After local anaesthesia, epidural, spinal or ketamine anaesthesia, respectively, were performed more often than general anaesthesia. During the 10-year period, only 12 patients were sent overseas for surgical treatment. Of the estimated 110 patients needing surgical treatment in Tuvalu each year, the great majority can be managed with present facilities. Regular visits by an eye and a plastic surgery team are useful, and a small number of selected patients need surgical treatment overseas. The adequate treatment of surgical emergencies from outer islands in an island community with great distances and poor communications remains the biggest challenge for surgical services in the future.

Blunt liver injuries. Resection vs. nonresection for primary hemostasis.

The records from 60 surgically treated cases of blunt liver injury during a 20-year period were reviewed. Preoperative shock was present in 26 (43%) of the patients. The severity of liver injury was graded 1-3. All of the 23 grade 1 injuries were managed with simple surgical techniques, with no deaths related to the hepatic trauma and only one hepatic complication. Of the 32 patients with grade 2 injury, 12 were managed with and 20 without liver resection. Resection did not increase mortality, morbidity, blood loss or hospital stay. Local hepatic bleeding complications were significantly rarer after resection. Reoperation for local hepatic complication was required three times as often in the nonresection as in the resection group. Only one of the five patients with grade 3 liver injury survived. The overall mortality in the series was 20%. Primary liver resection is suggested as a good option in the management of deep liver laceration.

Pancreatic trauma with proximal duct injury.

UNLABELLED: A retrospective study of patients with traumatic injuries to the head of the pancreas involving the main pancreatic duct but not the duodenum identified five cases comprising 0.5% of all abdominal, and 21% of pancreatic injuries managed operatively. Four of the injuries resulted from penetrating, and one from blunt trauma. Two patients treated with pancreaticoduodenal resection died of septic complications caused by the pancreatic procedures. Three patients undergoing duodenum-preserving pancreatic resection survived without developing diabetes during five months follow-up. CONCLUSIONS: Pancreatic trauma with proximal duct injury can in some cases be managed with distal subtotal pancreatectomy. If the resection would include more than 80% of the gland, a duodenum preserving resection of the head of the pancreas with distal Roux-en-Y pancreaticojejunostomy is a viable option providing the duodenum with its vasculature, the common bile duct, and the ampulla of Vater are uninjured. Unstable patients with severe associated injuries can be managed with external drainage alone.

Selective nonoperative management of abdominal stab wounds: prospective, randomized study.

In a prospective, randomized trial the safety and cost-effectiveness of selective nonoperative management was compared to mandatory laparotomy in patients with abdominal stab wounds not requiring immediate laparotomy for hemodynamic instability, generalized peritonitis, or evisceration of abdominal contents. Fifty-one patients were randomly assigned to mandatory laparotomy or expectant nonoperative management and compared for early (<90 days) mortality and morbidity, length of hospital stay, and hospital costs. There was no early mortality. The morbidity rate was 19% following mandatory laparotomy and 8% after observation (p = 0.26). Four patients (17%) managed nonoperatively required delayed laparotomy. The hospital stay was shorter in the observation group (median 2 days versus 5 days;p = 0.002). About $2800 (US) was saved for every patient who underwent successful nonoperative management. It is concluded that selective nonoperative management of abdominal stab wounds, although resulting in delayed laparotomy in some patients, is safe and the preferred strategy for minimizing the days in hospital with concomitant savings in hospital costs. Mandatory laparotomy detects some unexpected organ injuries earlier and more accurately but results in a high nontherapeutic laparotomy rate and surgical management of minor injuries that in many cases could be managed nonoperatively.

The role of laparoscopy in blunt abdominal trauma.

In a collective analysis of 11 reports with a total of 355 blunt abdominal trauma patients, the sensitivity and specificity of diagnostic laparoscopy in predicting the eventual need for therapeutic laparotomy were 94% and 98%, respectively, with an overall accuracy of 97%. Although fairly accurate and safe (morbidity rate about 1.2%), the invasiveness, cost and time-consuming nature of diagnostic laparoscopy limit its routine use in trauma patients. It could, however, be useful in selecting patients with minor or nonbleeding injuries for nonoperative management after positive peritoneal lavage or computed tomography, and in excluding occult bowel and diaphragmatic injuries in patients with equivocal findings, thereby reducing the number of unnecessary laparotomies. With the improvement of laparoscopic techniques and instrumentation, more injuries can probably be managed laparoscopically with all the benefits observed with the shift from open to laparoscopic procedures in other patient populations, and it is likely that laparoscopy will find its place as an integral part of evaluating and treating patients with blunt abdominal trauma. At present, however, laparoscopy cannot be recommended as a routine tool for evaluating patients with blunt abdominal trauma, except in controlled clinical trials.

Risk factors of delayed diagnosis of pancreatic trauma.

OBJECTIVE: To identify risk factors associated with delayed diagnosis of pancreatic injuries. DESIGN: Retrospective study. SETTING: University hospital, Finland. PATIENTS: 31 patients treated for pancreatic injuries from January 1986 to April 1998. INTERVENTIONS: Clinical, laboratory, and radiological assessment. Initial management operative (n = 22) and non-operative (n = 9). MAIN OUTCOME MEASURES: Timely or delayed (>12 hours after injury) recognition of pancreatic trauma. RESULTS: Blunt trauma (7/17 timely and 12/14 delayed diagnosis, p = 0.03), intoxication on admission (4/10 compared with 5/5 patients studied, p < 0.05), low New Injury Severity Score (median, interquartile 34, 11.5-41 compared with 14.5, 10-25, p = 0.02), low Abdominal Trauma Index (38, 20-54 compared with 16.5 15-24, p = 0.01), absence of associated abdominal organ injuries (1/17 compared with 8/14, p = 0.004), and initial nonoperative management (2/17 compared with 7/14, p = 0.04) were significant risk factors of delayed diagnosis of pancreatic trauma. The main reasons for the delay in diagnosis were missed pancreatic injury at initial operation (n = 4, 2 penetrating), failure to exclude blunt pancreatic injury before non-operative management (n = 4), delay in presentation (n = 3), underestimation of the severity of pancreatic injury on initial computed tomogram (n = 2), and missed diagnosis of blunt duodenal rupture with mild pancreatic injury (n = 1). CONCLUSIONS: In patients with blunt abdominal trauma and altered consciousness with few clinical signs, and no or mild associated abdominal injuries, we recommend additional diagnostic studies to exclude pancreatic rupture before starting non-operative management. Exposure and evaluation of the pancreas during laparotomy for trauma is essential.

Accidental injuries of the hepatoduodenal ligament.

OBJECTIVE: To report our experience in the management of accidental injuries to the structures of the hepatoduodenal ligament. DESIGN: Retrospective study of medical records. SETTING: University department of surgery. SUBJECTS: 8 patients admitted after accidents (road traffic accidents, n = 4; falls, n = 2; and gunshot and stab wounds, n = 1 each) who were found at laparotomy to have injuries of the structures of the hepatoduodenal ligament. INTERVENTIONS: Laparotomy in all cases. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: One patient died (13%) of multiple organ failure after a gunshot wound of the portal vein, liver, inferior vena cava, right renal artery, and right kidney. All patients had associated injuries. There were 3 complete transsections of the common bile duct, two of which were treated by Roux-en-Y cholecystojejunostomy and one by choledochojejunostomy over a T tube. Two lacerations of the common hepatic duct were treated by T tube choledochostomy. All injuries to blood vessels were sutured. Only one patient survived without any complications, and two developed cholangitis after cholecystojejunostomy that required further operation 5 and 16 months after the initial operation. CONCLUSIONS: Blunt injuries to the hepatoduodenal ligament are easily overlooked, leading to delayed morbidity. Complete transsections of the bile duct are best managed by choledochojejunostomy with a Roux-en-Y loop; T tube choledochostomy is usually sufficient when treating small partial lesions of lobar bile ducts; and most non-circumferential vascular lesions are best treated by suture.

Traumatic inferior vena caval injuries.

Twenty-three cases of inferior vena caval injury (1.4% of all operatively managed abdominal injuries) are reviewed. The caval injury presented as free haemorrhage in 15 cases and as a retroperitoneal haematoma in eight. The site of vena caval injury was at or above the level of the renal veins in 14 cases (61%). Successful lateral suture repair was achieved in 18 cases (78%). The overall mortality rate was 39%. Factors positively associated with survival were stab wound, presentation as retroperitoneal haematoma, infrarenal injury, low Abdominal Trauma Index score and small peroperative blood loss. Concomitant injury to the abdominal aorta, liver or kidney worsened the prognosis. The crucial factor in management of inferior vena caval injuries is rapid and effective control of bleeding, whether from the caval or associated injuries.

Civilian low velocity gunshot wounds of the liver.

OBJECTIVE: To report our experience in the management of hepatic gunshot wounds. DESIGN: Retrospective study of medical records. SETTING: University department of surgery, Finland. SUBJECTS: 38 patients admitted with hepatic gunshot wounds confirmed at operation. INTERVENTIONS: Laparotomy in all cases. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: Of the 35 low velocity bullet wounds of the liver, 23 (66%) were severe, but 34 (97%) could be managed with simple operative techniques. Two of the three shotgun injuries were at point-blank range, and one required lobectomy. Four patients (11%) died, and in all cases haemorrhage from associated cardiovascular injuries was a major contributing factor. Postoperative morbidity after bullet wounds was 57%, including two local hepatic complications. CONCLUSIONS: Simple operative repairs are sufficient and safe in most patients with low velocity bullet wounds of the liver. Associated injuries are the main cause of postoperative mortality and morbidity. Point-blank shotgun injuries involving the liver are not necessarily fatal.