Attempting primary closure for all open fractures: the effectiveness of an institutional protocol

Background

Immediate primary closure of open fractures has been historically believed to increase the risk of wound infection and fracture nonunion. Recent literature has challenged this belief, but uncertainty remains as to whether primary closure can be used as routine practice. This study evaluates the impact of an institutional protocol mandating primary closure for all open fractures.

Methods

We retrospectively reviewed all open fractures treated in a single level 1 trauma centre in a 5-year period. Prior to the study, a protocol was adopted standardizing management of open fractures and advocating primary closure of all wounds as a necessary goal of operative treatment. Patient and fracture characteristics, type of wound closure and development of infectious and bone healing complications were evaluated from time of injury to completion of outpatient follow-up.

Results

A total of 297 open fractures were treated, 255 (85.8%) of them with immediate primary closure. Type III open injuries accounted for 24% of all injuries. Wounds that were immediately closed had a superficial infection rate of 11% and a deep infection rate of 4.7%. Both proportions are equivalent to or lower than historical controls for delayed closure. Fracture classification, velocity of trauma and time to wound closure did not correlate significantly with infection, delayed union or nonunion.

Conclusion

Attempting primary closure for all open fractures is a safe and efficient practice that does not increase the postoperative risk of infection and delayed union or nonunion.     

Chest wall defect and chronic pleural infection: surgical treatment with thoracomyoplasty and open window thoracostomy

We report a rare case of a 75-year-old hemiplegic man with a chronic pleural infection, a bronchopleural fistula, and a full-thickness defect of the chest. In one operation we performed open-window thoracostomy and pleural decortication as well as reconstruction of the chest defect and reclosure of the bronchopleural fistula with a latissimus dorsi muscle flap. The patient made a good recovery and was sent for rehabilitation in good condition. Surgical treatment was essential to control and ultimately halt the septic process. Use of a muscle transplant in a hemiplegic patient did not reduce mobility.     

Evaluation of open window thoracostomy for chronic tuberculous empyema with broncho-pleural fistula; a retrospective analysis of 33 cases

We report here our 13-year experience treating chronic tuberculous empyema by open window thoracostomy. The subjects were 33 patients (28 males and 5 females) with a median age of 70 (range: 56-83) years who underwent surgery between January 1990 and December 2002. Patients with a history of pulmonary resection or thoracoplasty were excluded. All patients complained of cough and purulent sputum related to the presence of bronchopleural fistula. Previous illnesses included pulmonary tuberculosis (n = 20) and tuberculous pleurisy (n = 14) treated by artificial pneumothorax (n = 1) or chemotherapy (n = 22). Median duration from the initial episode of tuberculosis to surgery was 44 (range: 1-60) years. Mycobacterium tuberculosis (n = 9), Aspergillus fumigatus (n = 6), methicillin-resistant Staphylococcus aureus (MRSA) [n = 5], and Pseudomonas aeruginosa (n = 5) were representative microorganisms isolated from empyema. Preoperative mean %VC was 48 (range: 31-74)%. Mean follow-up was 34 (range: 1-131) months. Seven patients died of empyema-related disease within 6 months postoperatively. Nine patients underwent curative surgery to close the thoracostomy, including extrapleural pneumonectomy (n = 5), muscular transposition with thoracoplasty (n = 3), and lobectomy with muscular transposition and thoracoplasty (n = 1). In 17 patients, the thoracostomy was left open throughout the observation period because of severe impairment of pulmonary function. In elderly patients with severely impairment of pulmonary function, open window thoracostomy does not control empyema well and has a high rate of mortality.     

Congenital pseudoarthrosis of the clavicle: is operative treatment necessary? A report of four cases and literature review

Congenital pseudoarthrosis of the clavicle (CPC) is not a common condition. The exact number of cases reported in literature is fewer than two hundred. We present four well-documented cases of true congenital pseudoarthrosis of the clavicle, including two cases of familial occurrence. None of the patients in this study were treated surgically. Evaluation of upper extremity function was done with use of the Constant-Murley method. In spite of clavicle pseudoarthrosis the score results were similar to the unaffected shoulder. Although vertical elevation of the upper ribs or cervical ribs has been suggested as a cause of congenital clavicle lesions, radiological examination failed to reveal such pathology in any of the patients described here. Clavicle pseudoarthrosis is generally regarded as a benign condition. The majority of patients who underwent surgery because of cosmetic or functional heal well and proceed with a normal, unrestricted life. However, for those patients who are not bothered by the cosmetic appearance of their CPC and are asymptomatic in that they are not functionally limited, non-surgical treatment is a viable option.     

Perioperative nutritional support with immune-enhancing diet for surgical closure of open thoracic window

Immunonutrition, which is a therapeutic approach to modulate acute surgical or medical conditions, has been proven to decrease surgical site complications in patients undergoing major elective surgery for upper gastrointestinal and esophageal malignancy. For immunonutrition to be carried out effectively, specific nutrients called pharmaconutrients are quite important. In our case, to enhance the perioperative nutritional status of the patient, special formulas supplemented with specific pharmaconutrients, which are arginine and omega-3 fatty acids, were orally administered. The open thoracic window for chronic empyema caused by postoperative bronchopleural fistula was successfully closed. Perioperative immunonutrition is likely to have beneficial effect in decreasing postoperative infectious complications in high-risk malnourished thoracic surgical patients.     

后腹腔镜治疗肾上腺肿瘤35例临床分析

目的总结后腹腔镜技术治疗肾上腺肿瘤的临床经验.方法采用后腹腔镜切除肾上腺肿瘤35例,男12例,女23例.年龄25岁～72岁,平均49.8岁.左侧15例,右侧20例.其中嗜铬细胞瘤5例,原发性醛固酮增多症10,柯兴氏病2例,神经节细胞瘤2例,无功能性腺瘤16例.腰部取3个套管针穿刺入路,用自制的水囊扩张器扩张后腹腔,用超声刀将肿瘤切除.结果 35例手术均成功,无中转开放手术病例.术中出血量10～500 ml,平均74 ml.病人均未输血.手术时间45～200 min,平均90 min.结论后腹腔镜手术切除肾上腺肿瘤手术效果确切,手术时间短,术中出血少,损伤小,术后恢复快,可以替代绝大多数肾上腺肿瘤开放手术.     

Chylothorax after esophagectomy for cancer: impact of the surgical approach and neoadjuvant treatment: systematic review and institutional analysis

Background

Esophagectomy is a challenging operation with considerable potential for postoperative complications, including chylothorax.

Methods

Because no randomized controlled trial or metaanalysis is available to clarify the incidence of chylothorax in esophageal cancer surgery, the authors analyzed their own institutional data for 1,856 patients and performed a systematic review using the MEDLINE database (9,794 patients) to identify risk factors, compare success rates of therapeutic approaches, and investigate long-term outcomes.

Results

The overall institutional chylothorax rate was 2 % (n = 39). Reoperation was performed for 69 % of the patients. No significant difference was noted between the transthoracic and transhiatal approaches. Regression analysis showed neoadjuvant treatment (odds ratio [OR], 0.302; p = 0.001) and tumor type (OR, 0.304; p = 0.002) to be independent risk factors. The systematic review included 12 studies. Chylothorax occurred for 2.6 % of the patients. Treatment favored reoperation in five studies (70–100 %) and a conservative approach in four studies (58–72 %), with equal mortality rates. No significant difference was found between the transthoracic and transhiatal approaches.

Conclusion

Chylothorax rates are low in high-volume centers (2–3 %). No significant difference was noted between the transthoracic and transhiatal approaches. Neoadjuvant treatment and tumor type were shown to be independent risk factors. Treatment concept (reoperation vs conservative treatment) did not affect long-term survival.     

Adenocarcinoma of the stomach: A review of 35 years and 1,710 cases

The records of 1,710 patients with adenocarcinoma of the stomach treated at Charity Hospital over a 35-year period were reviewed to note any trends which might help in understanding the decreasing incidence and poor prognosis of the disease.The yearly number of gastric cancer patients has dropped from 234/100,000 in the 1950's to 195/100,000 in the 1960's to 108/100,000 patients in the last decade. The percentage of affected white males is decreasing at a rate equal to the increasing frequency of black female patients, while the ratios for black males and white females remain constant. The median age rose from 61.5 years to 66 years over the study period.The operability rate decreased from 82.4% to 72.8% and the resectability rate was 49%. Subtotal gastrectomy was the most common procedure, but radical subtotal gastrectomy gave the best 5-year survival.There are fewer lesions of the antrum today, but the highest number of 5-year survivors had antral lesions. Long-term survival of patients with lesions of the cardia improved from zero in the first 25 years to 14% in the last decade.For the last 2 decades, patients with stage III and IV lesions comprised one-half of the 5-year survivors.Our overall 5-year survival was 7.9%, but in the last decade it was 8.9%. Our 5-year survival for all patients who underwent a resection was 17.9%, but increased to 24.8% for the last decade. These improvements, in combination with a decrease in incidence, have dropped the overall mortality from gastric cancer.

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Resumen Se revisaron las historias clínicas de 1,710 pacientes con adenocarcinoma del estómago tratados en el Charity Hospital en un período de 35 años para identificar factores que pudieran ser ayuda para comprender la razón de la decreciente incidencia y el mal pronóstico de la enfermedad.El número anual de pacientes con cáncer gástrico ha descendido de 234/100,000 en los años 1950's a 195/100,000 en los 1960's y 108/100,000 en la última década. El porcentaje de hombres blancos afectados decrece a una tasa igual a la tasa de aumento en mujeres negras, en tanto que la relación para hombres negros y mujeres blancas se mantiene constante. La edad promedio ascendió de 61.5 a 66 años en el curso del estudio.La tasa de operabilidad disminuyó de 82.4% a 72.8% y la tasa de resecabilidad fue 49%. La gastrectomía subtotal fue el procedimiento más comúnmente utilizado, pero la gastrectomía subtotal demostró la mejor sobrevida a 5 años. Hoy se ven menos lesiones del antro pero el mayor número de sobrevivientes a 5 años tenía lesiones antrales. La sobrevida a largo plazo en los pacientes con lesiones del cardias mejoró de cero en los primeros 25 años a 14% en la última década.En las 2 últimas décadas los pacientes con lesiones en estados III y IV representaron la mitad de los sobrevivientes a 5 años.Nuestra tasa global de sobrevida a 5 años es de 7.9% pero en la ultima década fue de 8.9%. Nuestra tasa de sobrevida a 5 anos para la totalidad de los pacientes sometidos a resección es de 17.9%, pero ascendió a 24.8% en la última década. Tales progresos, junto con el descenso en la incidencia, han reducido la mortalidad por cáncer gástrico.

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Résumé Les dossiers de 1,710 patients ayant eu un adénocarcinome de l'estomac traités au cours des dernières années à l'Hôpital de la Charité (Nouvelle Orléans) ont été revus pour chercher des indices qui pourraient permettre de comprendre l'incidence décroissante et le mauvais pronostic de cette maladie.Le nombre de cancer gastrique par an est passé de 234/ 100,000 dans les années 50 à 195/100,000 dans les années 60 et à 108/100,000 dans la dernière décennie. Le pourcentage d'hommes de race blanche décroît, celui des femmes de race noire augmente, ceux des hommes de race noire et des femmes de race blanche restent stationnaires. L'âge médian a augmenté de 61.5 à 66 ans pendant la période d'étude.Le taux d'opérabilité a baissé de 82.4% à 72.8%, le taux de résectabilité était de 49%. La gastrectomie subtotale était pratiquée le plus souvent; la gastrectomie subtotale radical a donné la meilleure survie à 5 ans.Le nombre global de lésions antrales a diminué, mais les meilleures survies à 5 ans correspondent aux patients qui ont des lésions de l'antre. La survie à long terme des patients ayant un cancer du cardia est passée de 0% pendant les 25 premières années à 14% pendant la dernière décennie.Pendant les 2 dernières décennies, la moitié des survivants à 5 ans avaient des lésions de stade III et de stade IV.La survie globale à 5 ans était de 7.9%; celle de la dernière décennie de 8.9%. La survie à 5 ans pour tous les patients ayant eu une résection était de 17.9% et est passée à 24.8% pendant la dernière décennie. Nous pensons que la mortalité globale en rapport avec le cancer gastrique a diminué en raison de ces améliorations et du fait de la diminution de son incidence.

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Presented at the Société Internationale de Chirurgie in Toronto, Ontario, Canada, September, 1989.     

Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection

OBJECTIVE: Successful treatment of postoperative empyema remains a challenge for thoracic surgeons. We report herein our 12-year experience in the management of this condition by means of open window thoracostomy. METHODS: Open window thoracostomy was used in the treatment of 46 patients with empyema complicating pulmonary resection. A bronchopleural fistula was associated in 39 of 46 cases. Previous operations included pneumonectomy (n = 30), bilobectomy (n = 5), lobectomy (n = 9), and wedge resection (n = 2) performed for benign (n = 10) or malignant (n = 36) disease. In 10 patients open window thoracostomy was definitive because of patient death (n = 2), concomitant major illness (n = 2), tumor recurrence (n = 4), spontaneous closure (n = 1), or patient choice (n = 1). In 36 cases intrathoracic flap transposition was eventually performed. Muscular (n = 29), omental (n = 5), or combined muscular and omental (n = 2) flaps were used to obliterate the thoracostomy cavity and to close a possibly associated bronchopleural fistula. In 9 patients with postpneumonectomy cavities too wide to be filled by the available flaps, a limited thoracoplasty represented an intermediate step. RESULTS: Among patients treated with definitive open window thoracostomy, local control of the infection was achieved in all the survivors (8/8). After open window thoracostomy and subsequent flap transposition, success (definitive closure of the thoracostomy and, if present, of the bronchopleural fistula) was achieved in 27 (75. 0%) of 36 patients. Four initial failures could be salvaged by means of reoperation (initial reopening of thoracostomy and subsequent muscular or omental transposition). CONCLUSION: Open window thoracostomy followed by intrathoracic muscle or omental transposition represents a valid therapeutic option in patients with empyema complicating pulmonary resections.     

Ilioinguinal approach versus Stoppa approach for open reduction and internal fixation in the treatment of displaced acetabular fractures: A systematic review and meta-analysis

Purpose: To compare the efficacy and safety of open reduction and internal fixation through ilioinguinal approach and Stoppa approach for the treatment of displaced acetabular fractures. Methods: Case-controlled trials (CCTs) published from January 2010 to August 2015 that compared the ilioinguinal approach and Stoppa approach in the management of displaced acetabular fractures were retrieved from the databases of Cochrane Library, Pubmed, CNKI, and so on. Methodological quality of the trials was critically assessed. Statistical software RevMan 5.0 was used for data analysis. Results: Eight articles were included in the meta-analysis. Through comparing the efficacy and safety of ilioinguinal approach and Stoppa approach in the treatment of displaced acetabular fracture, statistical significance was found in the average operation time [WMD = 68.29, 95% CI (10.52, 126.05), p < 0.05] and the median intraoperative blood loss [WMD = 142.26, 95% CI (9.30, 275.23), p < 0.05]. However, there existed no statistical significance in the fracture end reset satisfaction rate [RR = 0.63, 95% CI (0.17, 2.37), p > 0.05], the early complications rate [RR = 0.89, 95% CI (0.33, 2.40), p > 0.05], the late complications rate [RR = 0.91, 95% CI (0.27, 3.01), p > 0.05], and Harris hip score good function rate [RR = 0.52, 95% CI (0.25, 1.10), p > 0.05]. Conclusion: Though both techniques can obtain satisfactory clinical functions in the treatment of displaced acetabular fractures, Stoppa approach is superior to the ilioinguinal approach in terms of operation time and intraoperative blood loss.     

异位胰腺的诊断与治疗:附35例病例报告

目的探讨异位胰腺的临床特点、诊断方法及外科处理原则。方法对我院自1996年7月至2006年8月经病理确诊的35例异位胰腺病人的临床特点、影像资料及治疗方法进行回顾性分析。结果本组35例病人中男16例，女19例，年龄18个月至74岁，平均43.5岁。单发33例，多发2例。异位胰腺分布部位：胃13例，十二指肠5例，空肠6例，结肠6例，胆囊、胆总管、后腹膜各1例，回、升结肠并发2例。术前仅6例确诊，8例误诊，21例漏诊。全组均经病理证实，4例内镜下高频电灼或电凝切除，31例手术治疗。随访2.4～8年，无一例出现术后并发症。结论异位胰腺的临床表现无特异性，易漏诊和误诊，内镜超声的临床应用能显著地提高诊断率。异位胰腺一旦出现症状，需早期内镜电凝或电切和手术治疗，以明确诊断及避免出现严重的并发症。无症状者无需治疗但应加强随访。     

肝海绵状血管瘤的外科治疗(附35例)

目的探讨肝海绵状血管瘤的手术指征和方法.方法对35例肝脏血管瘤的手术结果进行回顾性分析.结果35例中,单发者27例,多发者8例;肿瘤直径＜5 cm者8例,5～15 cm者22例,＞15 cm者5例;肝右叶22例,左叶7例,左右两叶6例.术前经彩超、CT、MRI、DSA等检查.35例均行手术,无手术死亡,并发症率22.9%（8/35）.结论对于瘤体直径＜5 cm不伴有临床症状且排除恶性者只须定期复查;对于瘤体直径＞5 cm伴有临床症状者,肝部分切除术和血管瘤剥离术是首选治疗方法.其手术的关键是如何控制和处理出血.     

Axis fractures: a comprehensive review of management and treatment in 107 cases

The combination of movement, location, and anatomy of the axis predisposes it to multiple and varied fracture/dislocations distinct from other vertebrae. We examine all forms of axis fractures and address the appropriate treatment for each specific fracture type. In a retrospective review of 625 cervical spine fractures during an 8-year period, we found 107 axis fractures. There were 25 hangman's fractures (23%), 59 odontoid fractures (55%), and 23 miscellaneous fractures (22%). Each case was characterized by age, sex, the presence of associated injuries, presenting symptoms and findings, initial treatment, and results of that treatment. Excluding 6 early deaths, 90 of 101 patients were located for a median follow-up of 3.2 years. We found that 17% of cervical fractures involve the axis. Axis fractures have a high association with head and other cervical spine injuries, 40% and 18%, respectively. Few neurological deficits result from a fracture of the 2nd cervical vertebra. Hangman's fractures are effectively treated with external stabilization, preferably with a halo vest. We noted a shorter period of treatment using the halo vest as compared to the SOMI brace. Nonunion occurred in 26% of odontoid Type II fractures, but occurred in 67% of those with dens displacement of 6 mm or greater, regardless of age or direction of dislocation. We recommend early surgical therapy for this subgroup. There is no correlation between age and the rate of nonunion. In patients with odontoid Type II fractures with dens displacement of 0 to 5 mm, fusion occurs with external stabilization alone. Odontoid Type III fractures are one-half as common as Type II fractures, and all heal well with external stabilization. Twenty-two per cent of acute axis fractures are not hangman's or odontoid fractures. Miscellaneous fractures of the axis generally do well with external stabilization and immobilization.     

Laparoscopic versus open treatment for benign pancreatic insulinomas: an analysis of 89 cases

Background  

The use of a laparoscopic approach in the treatment of insulinomas is increasing. This retrospective study aimed to evaluate the authors’ experience with laparoscopic surgery for benign pancreatic insulinomas and to compare the results for a laparoscopic approach versus an open approach.     

Successful closure of an open-window thoracostomy wound by negative-pressure wound therapy: report of a case

Negative-pressure wound therapy is a newly developed, noninvasive technique to manage a wide variety of wounds. This novel therapy was successfully used to heal the wound after open-window thoracostomy without surgical closure. A 46-year-old woman was admitted to hospital because of a painful mass on the right side of her chest. Radiological findings revealed an abscess on the right chest wall that had ruptured into the right lung and caused empyema. Antibiotic therapy did not yield sufficient improvement. Open-window thoracostomy was performed to achieve a sterile pleural space, and negative-pressure wound therapy was then applied. The pleural space was reduced, and the patient was discharged home with self-administered wound care. The wound healed completely in 5 months without any need for surgical closure.     

Operative treatment of acute Achilles tendon ruptures: an institutional review of clinical outcomes

PURPOSE: To retrospectively review the clinical outcome and incidence of post-operative complications after open end-to-end repair of acute Achilles tendon ruptures. METHODS: Seventy consecutive patients (74 open Achilles tendon repairs) operated on between 1989 and 2002 were identified for inclusion in this investigation. The medical records were reviewed and patients were contacted for a follow up interview in order to survey their post-operative function. Outcome scores were calculated based on the Boyden outcome and AOFAS ankle-hindfoot scoring systems. Post-operative complications were documented during the chart review and follow up interview, including an additional nine patients (nine repairs), who were not included in the clinical evaluation portion of the study. RESULTS: Fifty-two patients (54 repairs) were successfully contacted and completed the follow up interview. Within this cohort there were 44 males and 8 females with a mean age of 41 years. Achilles tendon rupture in this population was attributable to participation in athletic activity in 87% of cases. At a mean post-operative follow up of 45 months, 96% of cases achieved an overall Boyden outcome score of good to excellent. The mean AOFAS ankle-hindfoot score was 96, with 74% of cases scoring greater than 90. Forty-two cases (78%) reported no pain and 40 cases (74%) reported no activity limitations. Fourteen post-operative complications were identified after 83 open Achilles tendon repairs, resulting in an institutional complication rate of 16.8%. The complications included four superficial wound infections, five deep wound infections requiring irrigation and debridement, one heel ulcer secondary to post-operative boot wear, three partial Achilles tendon re-ruptures, and one complete Achilles tendon re-rupture. CONCLUSION: Our results demonstrate that open end-to-end repair of acute Achilles tendon ruptures provides long-term functional outcomes with consistent good to excellent results. However, this high clinical success rate was associated with a relatively high incidence of post-operative complications. With careful attention to the surgical wound and patient adherence to post-operative rehabilitation protocols, operative repair of acute Achilles tendon ruptures is a reliable treatment for active patients.