Jack M. Bergstein

Temporary abdominal closure (TAC) for planned relaparotomy (etappenlavage) in trauma

Planned relaparotomy (temporary abdominal closure) was studied prospectively in 20 trauma patients. Four died in the first 24 hours from hypothermia, coagulopathy, shock (three), and septic shock (one). The 16 survivors had a Velcro-like prosthetic placed to facilitate abdominal closure and re-entry. Prosthetic was necessary in eight because bowel edema precluded fascial closure, and useful for removal of packing (three) and for the management of peritonitis (five). The prosthetic did not open spontaneously, nor was it associated with evisceration or bowel fistula. Temporary abdominal closure (TAC) permitted reappraisal and staged repair of intra-abdominal pathology, including bowel resection and anastomosis. TAC identified 14 problems early: bleeding (five), bile leaks (two), GI complications (six), liver necrosis (one). Five patients developed superficial wound infections, and three went on to develop fascial necrosis.

Obturator hernia: Current diagnosis and treatment

BACKGROUND Obturator hernia is a rare pelvic hernia for which both diagnosis and therapy are difficult. Because symptoms are nonspecific and specific physical findings are often obscure, diagnosis of obturator hernia is often delayed until laparotomy for bowel obstruction. Strangulation is frequent, and mortality remains high (25%). Primary closure of the hernia defect is difficult because adjacent tissues are not easily mobilized. Although a variety of techniques have been described, surgical repair has not been standardized. METHODS We report a case of bilateral obturator hernia with incarceration in association with bilateral femoral hernia in which these problems were satisfactorily addressed. RESULTS The hernias were diagnosed by computed tomography (CT) scan and repaired with synthetic mesh placed in the preperioneal space. This technique is well suited to unilateral and bilateral combinations of obturator, inguinal, and femoral hernias. CT scan in the work-up of severe gastrointestinal symptoms with weight loss may lead to a diagnosis of occult hernia, thereby allowing elective repair and, hopefully, a reduction in mortality risk. CONCLUSIONS We recommend CT scan for suspected obturator hernia and preperitoneal mesh repair of noninfected cases.

Carcinoma of The Sigmoid Colon: An Unusual Cause of Fournier’s Gangrene

We report a case of perforated adenocarcinoma of the sigmoid colon in an inguinal hernia presenting as Fourniers gangrene. Bowel perforation has been known to cause this disease but, to our knowledge, perforation in an inguinal hernia due to benign or malignant disease has not been reported elsewhere. Gastrointestinal tract perforation should be sought as a potential etiology in patients with necrotizing fasciitis of the genitalia. When such a perforation exists occult malignancy should be ruled out.

Shock-associated right colon ischemia and necrosis.

Ischemic complications associated with hemorrhagic shock after blunt or penetrating trauma can result in acute renal, pulmonary, or hepatic failure. Less well described is the association between hemorrhagic shock and ischemic necrosis of the right colon, with only 14 cases reported in the literature. Herein, we report three previously healthy young trauma victims with shock-associated right colon necrosis. Each patient suffered a period of hypotension after injury. Diagnosis and operation took place within 2 days of initial injury in all three cases. In each patient, a right colectomy and primary anastomosis was performed without complication. Pathologic examination of the resected specimens showed ischemic necrosis, but no evidence of vascular thrombosis or embolic occlusion of the mesenteric vessels. The etiology of this type of ischemic colitis is not clear, but seems to represent a form of nonocclusive mesenteric ischemia. Knowledge of this disease process will lead to early recognition, prompt treatment, and a satisfactory outcome.

Stapled versus hand sewn anastomoses in patients with small bowel injury: a changing perspective.

INTRODUCTION Recent studies indicate that trauma patients with hollow viscus injuries requiring anastomosis who are managed with stapling have a higher rate of complications than do those in whom a hand-sewn anastomosis is used. We undertook this study to determine whether this finding applied to patients with small bowel trauma at our institution. METHODS Records of patients with small bowel injuries were retrospectively reviewed. Demographics, severity of injury, injury management, and outcome data were collected. RESULTS Patients who had their small bowel injuries managed by hand-sewn repair versus resection and stapled anastomosis demonstrated a nonsignificant decrease in overall complication rate (35% vs. 44%) and rate of intra-abdominal complication (10% vs. 18%). Yet the rate of intra-abdominal abscess formation was significantly lower with hand-sewn repair than with resection and stapled anastomosis (4% vs. 13%). However, when hand-sewn primary repairs were excluded from the analysis and injuries that required resection and either stapled or hand-sewn anastomosis were compared, there was a similar overall complication rate (41% vs. 41%) and rate of intra-abdominal complications (17% vs. 21%). CONCLUSION The rate of intra-abdominal complications did not differ significantly between patients requiring small bowel resection and reanastomosis managed by either a stapled or hand-sewn technique. In our experience, surgical stapling devices appear to be safe for use in repairing traumatic small bowel injury.

Traumatic Hypothermia Is Related to Hypotension, Not Resuscitation

STUDY OBJECTIVE To determine whether posttraumatic hypothermia is associated with hemorrhage or with resuscitation. METHODS We used a sequential hemorrhage-resuscitation rat model. Rats were subjected to hemorrhage (30 mL/kg), then 1 hour of shock, followed by 2:1 crystalloid/blood resuscitation (60 mL/kg) at ambient temperature. A control group underwent neither hemorrhage nor resuscitation. RESULTS We recorded core temperature and blood pressure every 10 minutes. Temperature drop averaged 3.4 degrees C and was fastest during hypotensive shock. Rate of temperature change correlated with blood pressure (beta = .0102, P < .001), shock phase (beta = .4504, P = .041), and blood pressure during shock phase (beta = .0116, P < .001), but not with resuscitation phase or with duration of shock or resuscitation. Three of 14 rats died during shock, none during resuscitation. An increase in temperature was noted in 1 of 14 rats during shock and in 7 of 11 rats during resuscitation. CONCLUSION Hemorrhage-associated hypothermia occurs during hypotensive shock, not during fluid resuscitation.

Pseudomembranous colitis: how useful is endoscopy?

SummaryClostridium difficile colitis may be diagnosed either by endoscopy or by laboratory tests. To determine the role of endoscopy, we reviewed 59 cases of confirmed C. difficile colitis. In all patients, the etiology was confirmed by stool tests. Twenty-nine underwent lower gastrointestinal endoscopy. In 16 (55%) there was endoscopic confirmation of pseudomembranes while 4 (14%) had only nonspecific colitis. There was no apparent difference in the rate of detection of pseudomembranes between rigid sigmoidoscopy (57%), flexible sigmoidoscopy (50%), and colonoscopy (50%). Vancomycin and metronidazole were equally effective therapy but treatment with vancomycin cost more than 250 times that for metronidazole. There were no patients in whom the diagnosis was made by endoscopy alone. Endoscopy was costly and insensitive, while noninvasive stool tests were cheap and accurate. We conclude that endoscopy should be relegated to a secondary role in the workup of antibiotic-associated diarrhea.

Calculated empiric antimicrobial therapy for mixed surgical infections

SummaryIn acute life-threatening surgical infections requiring immediate institution of antimicrobial therapy before bacteriological results are available, antibiotic treatment must be empiric. For best efficacy a more sophisticated form of empiric therapy is offered, termed calculated antibiotic therapy (CAT). Calculated antibiotic therapy requires consideration of a) typical bacterial spectrum; b) bacterial pathogenicity and synergism; c) antibacterial concentrations at the site of infection; d) toxicity and adverse effects; e) interaction with immune response; and f) results of properly conducted trials. Intraabdominal infections are used as an example here to assess the efficacy of clinically used cephalosporins and penicillins for determination of calculated antibiotic therapy. CAT identifiesEscherichia coli andBacteroides fragilis as the most important pathogens for intraabdominal infections and determines the most effective antibiotics at the tissue breakpoint, which is defined as the minimal concentration maintained for more than 90% of the dosage interval period at the infected tissues. At the tissue breakpoint calculated antibiotic therapy identifies cefotaximegeneration cephalosporins to be fully (100%) active against the most important aerobic pathogenE. coli and metronidazole as fully active against the important obligate anaerobeB. fragilis. Calculated antibiotic therapy becomes relatively important, since impeccably controlled clinical therapeutic trials as a foundation for therapy are rarely published.ZusammenfassungDie Therapie akuter lebensbedrohlicher chirurgischer Infektionen erfordert eine empirische initiale antimikrobielle Chemotherapie. Die kalkulierte antimikrobielle Chemotherapie (CAT) kann als eine Verbesserung der rein empirischen Therapie betrachtet werden. Sie erfordert, daß folgende Kriterien berücksichtigt werden: 1. Typisches Spektrum der Infektionserreger, 2. Pathogenität der Bakterien und deren infektiogener Synergismus, 3. Konzentrationen des Antibiotikums am Ort der Infektion, 4. Nebenwirkungen, 5. Störungen der Immunabwehr, 6. Ergebnisse sauberer kontrollierter klinischer Studien. Am Beispiel der intraabdomionalen Infektionen wird die Leistungsfähigkeit der CAT mit klinisch wichtigen Penicillinen und Cephalosporinen untersucht. Die CAT identifiziertEscherichia coli undBacteroides fragilis als die wichtigsten Infektionserreger der bakteriellen Peritonitis. nach CAT wird ein Tissue-Breakpoint als die Konzentration definiert, die während 90% des Dosisintervals am Ort der Infektion realisiert bleibt. Die effektivsten Antibiotika nach CAT sind Cefotaxim-Generation Cephaloporine, durch die 100% allerE. coli Bakterien (n=10413) am Gewebe-Breakpoint erfaßt werden und Metronidazol, durch das 100% aller obligaten Anaerobier der SpeziesB. fragilis (n=2345) bei Gewebe-Breakpoint Konzentrationen erfaßt werden. CAT gewinnt an Bedeutung, weil sich gezeigt hat, daß kontrollierte Studien mit Antibiotika nur selten qualitativ ausreichende Informationen enthalten, um als Therapiegrundlage verwertet werden zu können.