Management of complicated gastroschisis with porcine small intestinal submucosa and negative pressure wound therapy

Introduction

In almost all cases of gastroschisis, fascial closure may be achieved primarily or after silo reduction. Rarely, fascial and skin closure are impossible. We report our experience with visceral coverage in complicated cases of gastroschisis with porcine small intestinal submucosa (SIS) augmented by negative pressure wound therapy (NPWT).

Methods

Over a 3-year period, 55 infants with gastroschisis were managed. In 3 of these cases, fascia and skin could not be approximated safely after complete reduction of abdominal viscera with a spring-loaded silo. Visceral coverage in each case was achieved with 0.42-mm-thickness Surgisis ES (Cook Surgical, Bloomington, Ind) that was sewn to the fascial edges. Negative pressure wound therapy was then initiated at 75 mm Hg over the exposed SIS using vacuum-assisted closure.

Results

In each case, granulation tissue developed quickly and was followed by complete epithelialization. Two patients subsequently developed umbilical hernias.

Conclusion

We have successfully used SIS augmented by NPWT in the management of 3 infants with complicated gastroschisis. In the rare situation in which fascial closure cannot be achieved, the combination of SIS and NPWT can provide a safe and effective means of abdominal wall closure.     

Closed gastroschisis: total parenteral nutrition-free survival with aggressive attempts at bowel preservation and intestinal adaptation

Background

In infants with gastroschisis antenatal closure of the umbilical defect results in a proximal atresia with ischemia and/or volvulus of the extracorporeal midgut. It has been described as “closed gastroschisis” or “vanishing midgut.”

Methods

A 10-year review of 219 gastroschisis patients identified 10 infants with this rare complication.

Results

In these 10 infants, the extracorporeal midgut was invariably matted and fibrosed. In 3 cases, the midgut had completely “vanished.” In the remaining 7 cases, the remnant midgut was surgically reduced into the abdominal cavity with care not to compromise the diminutive vascular pedicle. Abdominal exploration was performed several weeks later to reestablish bowel continuity; 4 required an ostomy and 2 underwent a serial transverse enteroplasty. Mean residual length of salvaged small bowel was 79 cm with retention of the distal half of the colon. Eight infants survived the initial hospitalization, with a mean length of stay of 121 days and mean hospital charge of $287,094. Six of the 7 long-term survivors have been completely weaned off total parenteral nutrition.

Conclusion

A nihilistic attitude toward infants with closed gastroschisis may not be uniformly supported because in the majority of these infants' long-term independence from total parenteral nutrition was achieved.     

The burden of incisional hernia in necrotizing pancreatitis: how can we improve?

Background

Necrotizing pancreatitis (NP) patients frequently require pancreatic debridement, and have risk factors for incisional hernia (IH). However, no published data exist regarding the incidence of IH in NP. The aim of the current study was to define the incidence of and identify risk factors for developing IH after pancreatic debridement.

Methods

Hernia presence was determined by clinical examination and patient interview. Technical and clinical considerations were noted: type of incision, closure, suture material, age, body mass index (BMI), diabetes mellitus (DM), preoperative albumin, and number of operations.

Results

Sixty-three (42%) of 149 debrided patients with NP developed IH. IH patients were older (P < .05). No differences in surgical technique or clinical risk factors were seen between groups.

Conclusion

The incidence of IH in NP patients requiring operative debridement is substantially higher than that in patients undergoing routine laparotomy. Innovative fascial closure techniques such as primary fascial buttress with nonsynthetic mesh should be considered.     

Incisional hernia repair by fascial component separation: results in 128 cases and evolution of technique

Background

Most ventral incisional hernias are repaired using 1 of 2 principal techniques: (1) prosthetic repair (open or laparoscopic) and (2) primary reconstruction by fascial component separation. Primary midline restoration provides physiological advantages, and avoidance of mesh may reduce complications. This report describes 128 cases of incisional hernia repair by fascial release. Evolution of the technique produced modifications and fewer complications.

Methods

Fascial component separation was performed either by “classic” technique (broad skin flaps) in group 1 and by “perforator preservation” (fascial release through separate inferolateral incisions) in group 2.

Results

Mortality was .75% (1/128). Major complications occurred in 7 patients (5.5%). Total recurrence rate is 16% (21/128) with major recurrences in 9.3% (12/128). Both groups were statistically equivalent in demographics, comorbidities, and recurrences. Group 1 had significantly higher rates of skin necrosis (P < .001) and chronic pain (P = .003).

Conclusions

Fascial component separation can provide satisfactory results in uncomplicated incisional hernias, but skin necrosis is prohibitive without perforator preservation.     

New method of surgical delayed closure of giant omphaloceles: Lazaro da Silva's technique

Background/Purpose

The management of patients with a giant omphalocele remains a difficult problem. In this study, the authors described a new surgical approach for delayed closure of ventral hernia—the Lazaro da Silva’s technique—in conservatively treated patients.

Methods

Ventral hernias of 11 conservatively treated patients were corrected by Lazaro da Silva’s technique from 1987 to 2002 in Clinic’s Hospital of UFMG. The surgical procedure consisted of the bilateral longitudinal fibroperitoneal-aponeurotic transposition, resulting in 3 different layers of closure. The evolution of these patients is reported.

Results

The presence of associated anomalies was observed in 8 patients (73%), with a predominance of cardiac defects. No alterations were associated with the use of silver sulfadiazine for epithelialization. Despite the size of the ventral hernia, no difficulties were related to the surgical procedure. Furthermore, no peri- and postoperative complications were observed. The hospital stay was approximately 8 days. The aesthetic result was excellent in all patients, and no recurrence of ventral hernia was observed.

Conclusions

These results lead to the conclusion that conservative management of giant omphaloceles with delayed closure of the ventral hernia using Lazaro da Silva’s technique is a safe and reliable approach for treating these critically ill patients.     

Peroperative Gastrograffin bowel lavage in gastroschisis

Aims

The aim of the study was to evaluate potential benefits in the use of peroperative bowel lavage with Gastrograffin in neonates with gastroschisis.

Methods

A retrospective analysis of newborns with gastroschisis was performed over a 10-year period in 2 centers in the United Kingdom. Two groups were studied wherein one had peroperative bowel lavage with Gastrograffin and the other did not.

Results

Data were collected on 116 patients of whom 93 were suitable for analysis. There were no statistically significant differences in primary closure rate, duration of ventilation, parenteral nutrition, or hospital stay. Intestinal obstruction occurred more frequently in the nonlavage group.

Conclusion

Gastrograffin lavage peroperatively in gastroschisis offers no potential advantage in reducing ventilatory requirements, parenteral nutrition, and hospital stay. It also does not achieve greater primary closure rates, but may reduce the incidence of intestinal obstruction.     

Comparison of pharyngeal stenosis between hypopharyngeal patients undergoing primary versus salvage laryngopharyngectomy

Objective

To survey the risk factors of pharyngeal stenosis after laryngopharyngectomy in patients with advanced hypopharyngeal cancers.

Study Design

Case series with chart review.

Setting

Tertiary medical center.

Subjects and Methods

Pharyngeal stenosis rates and risk factors were compared between two groups of laryngopharyngectomy patients: a group that underwent concurrent chemoradiation therapy followed by surgical salvage, and a surgery initiated group with adjuvant chemoradiation.

Results

Of 160 patients, 25 developed pharyngeal stenosis, which was diagnosed by barium esophagography with a pooling of barium contrast above the neopharyngeal inlet. These patients required nasogastric tube feeding or gastrostomy feeding because an oral liquid diet could not meet their nutritional needs. Primary closure and old age were risk factors for pharyngeal stenosis. Pharyngeal stenosis did not affect survival in patients with advanced hypopharyngeal cancer who underwent laryngopharyngectomy.

Conclusion

Primary closure reconstruction is discouraged in patients over the age of 65 years.     

Reduction of surgical site infections by use of pulsatile lavage irrigation after prolonged intra-abdominal surgical procedures

Background

Surgical site infections cause significant postoperative morbidity and may be reduced by pressurized irrigation of high-risk laparotomy wounds before closure. This was a retrospective review (June 2007 to May 2008) from a surgical unit at a tertiary care center.

Methods

Patients undergoing laparotomy extending beyond 4 hours, when a standard wound management strategy was instituted by either simple irrigation or pressurized pulsatile lavage (<15 psi) with saline before closure, were included. The outcome measures were the surgical site infections and factors contributing to them.

Results

The median surgical time for the patients was 8 hours, with 34 wounds managed by simple irrigation and 42 wounds managed by pulse irrigation. Both groups had similar characteristics. Overall there were 15 (20%) surgical site infections. Significantly fewer infections occurred in the pulse irrigation group (10% vs 32%; P = .019). The use of a pulse irrigation device was the only factor associated with a reduction in wound infections (P = .019).

Conclusions

Surgical site infections appear to be reduced with pulsatile lavage irrigation of wounds before skin closure in patients undergoing prolonged intra-abdominal surgeries.     

Terlipressin as Rescue Therapy in Catecholamine-Resistant Hypotension in Solid Organ Donors: A Case Report

Objective

The objective of this study was to report the effects of Terlipressin treatment in 2 potential organ donors with intractable, catecholamine-resistant hypotension.

Design and Setting

This study was based on case reports in the intensive care unit of a general hospital.

Patients

Patients included 2 adult patients with cerebral death and catecholamine-resistant hypotension.

Interventions

A low dose of Terlipressin (3.5 μg/kg) by intravenous bolus was added to the standard treatment.

Measurement and Results

In both cases, Terlipressin induced a rapid improvement in arterial pressure with a consequent increase in urine output and the appearance of diabetes insipidus. In 1 patient it allowed for the withdrawal of norepinephrine infusion. No related adverse effects were detected in either patient. Organ removal was not possible in the second case due to lack of family consent.

Conclusions

Terlipressin might be considered as a rescue therapy for potential organ donors with intractable, catecholamine-resistant hypotension. In spite of the positive results obtained here and by other authors in the treatment of septic shock, its judicious use is recommended, and an optimal administration schedule must still be elucidated.     

Conservative management of giant omphalocele with topical povidone-iodine and its effect on thyroid function

Purpose

The aim of the study was to evaluate topical povidone-iodine as a bridge to delayed fascial closure of giant omphaloceles with emphasis on its effect on thyroid function.

Methods

Newborns from a single institution with giant omphaloceles treated with topical povidone-iodine for a 10-year period were reviewed. Recorded data included sex, associated anomalies, length of stay, frequency of povidone-iodine application, thyroid function tests, frequency of laboratory draws, and thyroid supplementation administration.

Results

Six neonates with giant omphaloceles were treated with povidone-iodine. Thyroid function testing occurred weekly as inpatients and monthly as outpatients, with abnormal values normalized by the subsequent laboratory draw. One patient demonstrated persistent hypothyroidism and subsequently died secondary to cardiac complications, but this infant's newborn thyroid screening suggested congenital hypothyroidism. Five patients remained euthyroid and ultimately achieved fascial closure without the need for a prosthetic implant. None of these patients had abnormal outpatient thyroid tests nor did they require thyroid hormone supplementation.

Conclusion

Topical povidone-iodine promotes escharification and epithelialization of the omphalocele sac. Because transient hypothyroidism may occur, thyroid function studies may guide inpatient therapy. After sac desiccation, systemic effects of iodine are minimal and thyroid supplementation is not necessary. Topical povidone-iodine is an effective initial strategy for giant omphaloceles and does not produce clinically significant hypothyroidism.     

Contouring buttock reconstruction after sacrococcygeal teratoma resection

Purpose

Massive sacrococcygeal teratomas are typically resected and closed in a “chevron” fashion. The resultant scar may leave protuberant “dog ears” and extend across and below the infragluteal creases down onto the posterior thighs, causing undesirable buttock deformity. Given the redundant skin often available, the authors sought to develop a closure technique to minimize deformity and unpleasant scars.

Methods

At the time of resection of 2 sacrococcygeal teratomas, attention was directed to minimizing redundant skin, restoring normal buttock contour, and avoiding scars crossing the infragluteal crease. After properly securing the anal location, serial polygonal skin excisions were performed, working the excess tissue centrally rather than peripherally, leaving 2 right-angled scars on each buttock.

Results

Each infant underwent successful reconstruction with a normal buttock contour without redundancy. All scars on the buttocks can be easily covered by bathing attire.

Conclusions

The excess skin expanded by large sacrococcygeal teratomas affords an opportunity to apply straightforward tissue rearrangement principles to reconstruct the buttocks with a normal contour and hidden scars.     

The use of human acellular dermis in the operative management of giant omphalocele

Purpose

The management of giant omphalocele presents a major challenge to pediatric surgeons. Current treatment modalities often result in wound infection, fascial separation, and abdominal domain loss. Human acellular dermis (AlloDerm), as a primary abdominal fascial substitute, may prevent these complications. We present our experience with its application in neonates with giant omphalocele.

Methods

Charts of patients with giant omphalocele from January 2003 to September 2004 were reviewed and data collected regarding wound healing, rate of infection, ventilatory support, and outcome.

Results

Three neonates underwent abdominal wall closure with AlloDerm (gestational ages: 38, 37, and 28 weeks; birthweights 2880, 2640, and 1160 g, respectively). All had cardiac anomalies; 1 required cardiac surgery and 1 was ventilator-dependent, secondary to pulmonary hypoplasia. Omphalocele repair was performed on day-of-life 9, 2, and 87. No fascial dehiscence or infection was encountered. Neovascularization was noted by day 7. Two died of cardiopulmonary disease (6 months and 1 year). The third exhibited normal growth and development without complication.

Conclusions

AlloDerm provides visceral coverage without compromising cardiopulmonary function, diminishing abdominal domain, or requiring multiple operations, allowing prompt treatment of associated anomalies. AlloDerm represents an exciting alternative in the treatment of giant omphalocele. Further study is required to determine long-term benefits.     

Surgery improves quality of life in patients with “mild” hyperparathyroidism

Background

Surgical treatment of patients with “classic” hyperparathyroidism improves quality of life, but these benefits to patients with “mild” disease remain unclear.

Methods

The SF-36 Health Survey was administered to 174 patients 1 week before, 1 week after, and 1 year after undergoing parathyroidectomy.

Results

One hundred fifty-one patients completed at least 2 surveys. There were 18 and 133 cases of “mild” and “classic” hyperparathyroidism, respectively. Preoperatively, the groups did not differ significantly in the 10 scales. One year after surgery, patients with “classic” and “mild” disease improved significantly in 9/10 and 10/10 scales, respectively (P < 0.05). Those with “mild” disease had a statistically larger improvement than those with “classic” disease in 4 scales.

Conclusions

Quality of life significantly improved in surgically treated patients with both “mild” and “classic” hyperparathyroidism, supporting surgical treatment of “mild” hyperparathyroidism. Moreover, quality of life may improve more in patients with “mild” rather than “classic” disease.     

Local wound exploration remains a valuable triage tool for the evaluation of anterior abdominal stab wounds

Background

Recent guidelines do not support local wound exploration (LWE) or diagnostic peritoneal lavage (DPL) in the evaluation of patients with anterior abdominal stab wounds (AASWs), favoring computed tomography scanning or serial examinations. In patients without immediate indications for laparotomy, we hypothesized that LWE/DPL would identify patients requiring surgery while limiting unnecessary hospital admissions.

Methods

Patients sustaining penetrating trauma at our level I trauma center over a 3-year period were reviewed.

Results

During the study period, 139 patients with AASW followed our LWE/DPL algorithm. Fifty-six patients had LWE without fascial penetration: 46 were discharged immediately, 10 required admission. Fifty-eight patients had fascial penetration on LWE but negative DPL: 37 were observed for less than 24 hours, 19 were observed for more than 24 hours, and 2 patients developed peritonitis requiring exploration. Twenty-five patients had positive LWE/DPL: 13 had therapeutic laparotomy, 12 had nontherapeutic laparotomy.

Conclusions

Only 11% of patients with AASWs without overt indication for laparotomy require surgical care. LWE remains a valid method to exclude intra-abdominal injury and to eliminate hospitalization in more than one third of AASW patients.     

Surgical intervention in the setting of parenteral nutrition-associated cholestasis may exacerbate liver injury

Purpose

This study compares postoperative markers of liver injury in patients receiving intravenous fish oil (IFO) with parenteral nutrition (PN)-associated cholestasis (PNAC) to patients with resolved PNAC.

Methods

A retrospective review of all cholestatic-IFO patients undergoing abdominal laparotomy between March 1, 2007, and July 1, 2009, led to inclusion of 23 patients who collectively underwent 27 abdominal operations (13 pre-PNAC resolution and 14 post-PNAC resolution). Direct bilirubin (DB), total bilirubin, and alanine aminotransferase levels were examined over time in relation to operations. The time to resume presurgical trend of decreasing DB was calculated.

Results

Sixty-nine percent (9/13) of pre-PNAC resolution procedures were associated with postoperative increase in DB compared with 7% (1/14) of post-PNAC resolution procedures associated with a recurrence of cholestasis (P = .02; odds ratio, 29.3; 95% confidence interval, 2.79-306.8). The median time to return to the preoperative downward trend of DB was 21 days.

Conclusions

Operations before PNAC resolution may be associated with an increased postoperative DB, possibly reflecting an exacerbation of liver injury. Operations post-PNAC resolution on IFO had a comparatively low incidence of postoperative cholestasis recurrence. Excepting clinical indication otherwise, it may be advisable to delay surgical intervention in the setting of PNAC in certain cases.     

Laparoscopic repair of traumatic bowel injury in children

Purpose

The aim of this study was to evaluate the laparoscopic repair of isolated intestinal injuries in children who sustain focal abdominal trauma.

Methods

A retrospective review was conducted of all patients 16 years and younger who required surgery for traumatic bowel injuries during a 5-year period at 2 university children's hospitals. The study population was composed of hemodynamically stable patients who sustained focal energy transfer to the abdomen and were diagnosed preoperatively with intestinal injury. Children sustaining multisystem injuries and gunshot wounds or who were hemodynamically unstable were excluded.

Results

Fifty hemodynamically stable children were explored for preoperatively documented intestinal injury sustained after focal abdominal trauma. Laparoscopy was used to repair intracorporeally gastrointestinal injuries in 8 children. Mean operating time, time to diet, and time to discharge after laparoscopic bowel repair compared favorably with patients managed by laparotomy. An additional 6 patients had a laparoscopic-assisted bowel resection or repair after exteriorization only of the ruptured intestine through a short extension of the nearest port site. No early (missed injury, wound infection, bleeding) or late (obstruction) complications resulted after laparoscopic repair.

Conclusions

Laparoscopic primary or assisted repair of injured bowel is an appropriate surgical option in hemodynamically stable children who sustain focal abdominal trauma and may be associated with a more prompt return of intestinal function and shorter hospital stay.     

Preliminary clinical experiences of a motorized manipulator for magnetic resonance image–guided microwave coagulation therapy of liver tumors

Background

In magnetic resonance (MR) image-guided microwave thermocoagulation of liver tumors, the choice of the optimal puncture route is an important and time-consuming process. To assist this process, we have developed a motorized MR-compatible manipulator.

Methods

The manipulator consists of a passive end effecter with 2 degrees-of-freedom (DOF) rotation and active base stages with 3 ultrasonic motors. It automatically chases the preset target point with synergetic remote-center-of-motion (RCM) control. A mechanical torque limiter and an electrical shutdown switch were added for patient safety.

Results

The manipulator was used for this procedure in 15 cases and successfully utilized to treat liver tumors in various locations. Thoracoscopic assistance was combined with the manipulator in 6 cases. No complications were experienced.

Conclusions

The manipulator was found to be very effective for assisting MR-guided microwave coagulation of liver tumors.     

Utilidad de la tomografía computarizada para el diagnóstico de lesiones intestinales y mesentéricas en el trauma abdominal cerrado

Background

The frequency of bowel and mesenteric injuries is increasing. They are difficult to diagnose and delays in their diagnosis leads to a significantly increased morbidity and mortality. The aim of this study is to evaluate the usefulness of the computed tomography (CT) in the detection of blunt bowel and mesenteric injuries.

Method

Between January 2000 and October 2007, 79 patients with blunt abdominal trauma (60 men and 19 women) were included in our study. They underwent laparotomy after performing the abdominal CT. The CT findings were compared with the findings at laparotomy in order to determine the accuracy of the CT in the detection of bowel and mesenteric injuries.

Results

For the detection of bowel and mesenteric injuries we obtained for the CT: Sensitivity=84.2%, Specificity=75.6%, Positive Predictive Value =76.2%, Negative Predictive Value =83.8%, Positive Probability Value=3.45 and Negative Probability Value =0.21. Accuracy: 79.7%.

Conclusion

The abdominal CT is suitable for detecting bowel and mesenteric injuries following blunt abdominal trauma.     

Hypersensitivity reaction against patent blue during sentinel lymph node removal in three melanoma patients

Background

In order to identify the sentinel lymph node (SLN) in melanoma patients intradermal injection of a radiocolloid tracer and a blue dye are commonly used. Life-threatening side effects such as allergic reactions to the injected dye have been described. We report 3 cases with systemic allergic reactions.

Methods

Three patients suffering from systemic reactions such as hypotension and rash during SLN biopsy were tested for sensitisation against patent blue and methylene blue with skin prick, scratch, and intradermal test.

Results

All 3 patients showed positive skin tests to patent blue confirming allergic reaction to the injected dye. In addition, all patients showed positive skin tests with methylene blue indicating immunologic cross-reactivity between patent blue and methylene blue.

Conclusions

Although allergic reactions to blue dye during SLN biopsy are rare, they may be life threatening. It is important that the attending anesthetist is aware of this.     

First reported experience with intramuscular diaphragm pacing in replacing positive pressure mechanical ventilators in children

Purpose

Diaphragm pacing (DP) has been shown to successfully replace mechanical ventilators for adult tetraplegic patients with chronic respiratory insufficiency. This is the first report of DP in ventilator-dependent children.

Methods

This was a prospective interventional experience under institutional review board approval. Diaphragm pacing involves outpatient laparoscopic diaphragm motor point mapping to identify the site where stimulation causes maximum diaphragm contraction with implantation of 4 percutaneous intramuscular electrodes. Diaphragm conditioning ensues to wean the child from the ventilator.

Results

Six children were successfully implanted ranging from 5 to 17 years old with the smallest 15 kg in weight. Length of time on mechanical ventilation ranged from 11 days to 7.6 years with an average of 3.2 years. In all patients, DP provided tidal volumes above basal needs. Five of the patients underwent a home-based weaning program, whereas one patient who was implanted only 11 days post spinal cord injury never returned to the ventilator with DP use. Another patient was weaned from the ventilator full time but died of complications of his underlying brain stem tumor. The remaining patients weaned from the ventilator for over 14 hours a day and/or are actively conditioning their diaphragms.

Conclusion

Diaphragm pacing successfully replaced mechanical ventilators, which improves quality of life.