Managing chronic, nonhealing wounds using a research-based protocol

The physical, emotional, and financial costs of caring for patients with chronic, nonhealing leg wounds are substantial. In fiscal year 2001, the home care department of a large Veterans Affairs medical center in the Pacific Northwest spent nearly half of its annual budget on veterans needing wound care. In this article, the authors describe a practice improvement project designed to improve the wound care management of homebound veterans with chronic, nonhealing lower extremity wounds using a research-based protocol and consultation by a certified wound care specialist, as well as the effect of this program on home care expenditures.     

Innovative marking method using novel endoscopic clip equipped with fluorescent resin to locate gastric cancer

An asymptomatic 76-year-old man presented to our department for the treatment of gastric cancer. Esophagogastroduodenoscopy revealed a superficial elevated lesion with an irregular central depression in the lower third of the stomach; this was confirmed to be adenocarcinoma by biopsy, while abdominal contrast-enhanced CT revealed no abnormal lesions. Based on the patient's clinical diagnosis of early gastric cancer, we planned laparoscopic gastrectomy with preoperative placement of four endoscopic marking clips equipped with indocyanine green-conjugated resin to determine the resection margin. During surgery, a dedicated laparoscopic system was used to detect indocyanine green fluorescence emitted by the clips and determine their precise position. The clips helped to identify an accurate resection line for the stomach, enabling accurate laparoscopic distal gastrectomy with regional lymphadenectomy. We successfully demonstrated the usefulness of clips with fluorescent resin for detecting gastric cancer in patients. We report the first case using the clips to accurately locate a site of interest.     

Long-term efficacy and safety of a nitinol closure clip system for anal fistula treatment

Introduction: Treatment failure of anal fistula results in high re-occurrence rate.

Material and methods: Efficacy and safety of a nitinol closure clip system (bear-claw clip) were evaluated for anal fistulae treatment in a 36-month long-term follow-up study.

Results: Twenty-two patients were included. No patient had been treated with a bear-claw clip system before. All patients were fully continent before treatment. Follow-up time was 36 months (range 19–48 months). We observed a re-occurrence rate of 41% (nine patients) with presence of an active fistula. Time to recurrence was on average 6.9 months (range 3–11 months). Thirteen patients (59%) showed a complete healing of the fistula. Placed clip was removed in all patients on average after almost 5.8 months (3–12 months), in three cases the clip was left in situ. We did not observe any incontinence; one patient reported recurrent burning after defecation once the clip system was removed.

Discussions: Clip placement is a minimally invasive sphincter-preserving procedure with minimal complications and with an acceptable recurrence rate in the long term. However, bear-claw clip placement should probably be offered patients as a treatment option before more invasive procedures with higher perioperative morbidity are taken into consideration.     

Persistence of gastrocutaneous fistula after removal of gastrostomy tubes in children: prevalence and associated factors

BACKGROUND AND STUDY AIMS: The aims of this study were to determine the prevalence of gastrocutaneous fistula after removal of gastrostomy tubes in children and to identify associated risk factors. PATIENTS AND METHODS: The records of children who had undergone removal of gastrostomy tubes between January 1992 and December 2002 were reviewed retrospectively. Persistent gastrocutaneous fistula was defined as the absence of closure of the gastrostomy 1 month after tube removal. Factors that might influence spontaneous closure of the gastrostomy were studied, including age, underlying disease, nutritional status, type of gastrostomy, replacement of the gastrostomy tube by a button, abdominal wall thickness, duration of gastrostomy tube or button placement, and complications related to the presence of the gastrostomy (infection, granulation tissue). RESULTS: A total of 44 patients were included in the study (mean age 20 months, range 1 day to 14 years). Of these, 28 had undergone percutaneous endoscopic gastrostomy and 16 surgical gastrostomy. The mean time to spontaneous closure was 6 +/- 7 days. Persistent gastrocutaneous fistula developed in 11 patients (25 %) and in seven of these patients this required surgical closure (16 %). The mean duration of gastrostomy placement was significantly longer in patients who went on to develop a gastrocutaneous fistula than in patients who did not develop a fistula (39 +/- 19 months vs. 22 +/- 23 months, respectively, P < 0.03). No other significant association was found between the time required for spontaneous closure and the characteristics of patients or the type of gastrostomy. CONCLUSIONS: Persistent gastrocutaneous fistula is common after removal of gastrostomy tubes in children. Surgical closure should be considered when a gastrostomy has not closed spontaneously 1 month after removal of the gastrostomy tube.     

A case of endoscopic treatment for gastrocolocutaneous fistula as a complication of percutaneous endoscopic gastrostomy

As a rare complication of percutaneous endoscopic gastroscopy (PEG), a gastrocolocutaneous fistula may occur after PEG placement. This paper reports an interesting case which PEG tube unintentionally penetrated transverse colon during PEG. A 72-year-old female patient who suffered from medullary infarction underwent PEG procedure for enteral nutrition, and fecal materials were observed 6 days after the procedure. Transverse colon located in antero-superior site of stomach was observed through abdominal computed tomography, and also the wrong inserted tube was found through gastroscopy and colonoscopy. Endoscopic treatment for the fistula was performed by the use of hemo-clip and detachable snare, closure of the fistula was finally confirmed 6 days after the endoscopic procedure. Therefore, the gastrocolocutaneous fistula should be considered as one of the complications of PEG when fecal material is observed through PEG tube in a few days after PEG procedure and endoscopic treatment can be feasible in this case.     

Closure of spontaneous cerebrospinal fluid leakage via fistula at the lateral wall of the sphenoid sinus using a bone pile

This report describes a case of spontaneous cerebrospinal fluid leak through a narrow canal‐like fistula in the lateral wall of the sphenoid sinus, which was managed through rigid reconstruction. Rigid reconstruction of the skull base was performed by fitting a pile‐shaped bone into the fistula like the pile‐driving technique.     

新型可降解吻合夹吻合血管的生物力学特点

背景：目前国内外应用于临床的血管吻合器均可以克服传统血管吻合方法操作复杂、吻合时间长和内膜损伤等严重缺陷。但其不可吸收的针环影响了吻合口处血管正常收缩与舒张的生理功能,从而限制血管的生长,不适宜未成年患者。目的：分析新型可降解的吻合夹吻合血管的生物力学特点。方法：剪断新西兰大白兔双侧颈静脉,一侧应用新型可完全降解的吻合夹吻合,另一侧行针线吻合对照,测定术后当天,第7,14,30天时离体血管吻合口的平均破裂压。结果与结论：吻合夹组吻合时间短于针线吻合法（P 〈0.05）,吻合夹组平均破裂压与针线吻合法组比较差异无显著性意义（P 〉0.05）。生物力学表明新型可降解的吻合夹安全可靠。     

Feasibility study on endoscopic suture with the combination of a distal attachment and a rotatable clip for complications of endoscopic resection in the large intestine

BACKGROUND AND STUDY AIMS: Endoscopic resection has been more frequently performed for increasingly larger intramucosal tumors of the large intestine in recent years. It is reasonable to expect that the larger the resected mucosal surface, the greater is the likelihood of complications such as bleeding or perforation. The aim of this study was to explore the feasibility of endoscopic suture with a distal attachment and a rotatable clip-fixing device for complications of endoscopic resection in the large intestine. PATIENTS AND METHODS: The study population consisted of 15 patients who underwent endoscopic clipping therapy following endoscopic resection for intramucosal tumors of the large intestine. With a distal attachment fitted to the distal end of the endoscope, the optimal position for clipping was ensured by pressing the intestinal wall and deflating the intraluminal air little by little. With a rotatable clip-fixing device, the resection site was endoscopically sutured clip by clip. RESULTS: Tumors were of the laterally spreading tumor type in six patients, small sessile polyps in three, and pedunculated polyps in six. The complications consisted of bleeding in 12 patients, overt perforation in one, and latent perforation in two; 14 of the 15 patients underwent successful suturing by this method. The number of clips used ranged from two to seven (mean 4.4). No patients had further complications after the treatment. CONCLUSION: We conclude that endoscopic suture with the combination of a distal attachment and a rotatable clip-fixing device is very useful for complications of endoscopic resection in the large intestine.     

Endoscopic titanium clip closure of gastric fistula after splenectomy: A case report

This report describes a 52-year-old male patient with blunt abdominal traumatic rupture of the spleen due to injuries sustained in an automobile accident. Following splenectomy, the patient developed a gastric fistula. He underwent a long period of conservative treatment, including antibiotics and total parenteral nutrition, which was ineffective. The fistula could not be closed and titanium clip closure using a gastroscopy was then performed in order to close the fistula. After endoscopic therapy and clipping surgery, the patient’s general condition improved significantly, and he had no post-procedural abdominal complications. On post-clipping day 6, the gastric fistula was completely closed as shown by X-ray examination of the upper digestive tract. The patient was discharged from hospital and no complications were observed during the six-month follow-up period. Our report suggests that titanium clip closure using endoscopy may be the choice of treatment in patients with a gastric fistula.     

内镜下钛夹治疗非静脉曲张性上消化道出血的疗效观察

上消化道出血为临床常见急症 ,非静脉曲张性上消化道出血最常见的原因有消化性溃疡、血管病变、炎症、黏膜病变、肿瘤等。目前所采用的方法有内镜下电凝、热探头、内镜下注射及药物治疗 ,对于反复发作的小动脉出血及溃疡基底部持续喷血者 ,钛夹止血优于其他治疗方法。我院自 2 0 0 0年 5月使用内镜下钛夹治疗消化道出血患者 34例 ,收到了显著的疗效。1　资料与方法1.1　病例选择　本组 34例患者 ,均以反复呕血、便血病史入院 ,并经输血、补液及药物治疗等未能控制病情 ,入院后行紧急胃镜检查 ,发现活动性出血而行胃镜下钛夹止血治疗。其中男…